Provider Demographics
NPI:1174938906
Name:WHARTON-LAKE, DJAVAN
Entity type:Individual
Prefix:
First Name:DJAVAN
Middle Name:
Last Name:WHARTON-LAKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 WEBSTER ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20011-4656
Mailing Address - Country:US
Mailing Address - Phone:301-996-4055
Mailing Address - Fax:
Practice Address - Street 1:2045 UNIVERSITY BLVD E STE 204
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20783-4137
Practice Address - Country:US
Practice Address - Phone:626-254-0207
Practice Address - Fax:626-254-8679
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-01
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA650361223E0200X
SCDGD.10963DS1223E0200X
MD177871223E0200X
VA04014177761223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics