Provider Demographics
NPI:1316167448
Name:WASHINGTON, ADRA GIBSON (DMD)
Entity type:Individual
Prefix:
First Name:ADRA
Middle Name:GIBSON
Last Name:WASHINGTON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 ARCADE UNIT 198747
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37219-1994
Mailing Address - Country:US
Mailing Address - Phone:615-753-0343
Mailing Address - Fax:615-986-1705
Practice Address - Street 1:3439 MCGEHEE RD STE B
Practice Address - Street 2:UNIT 22
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36111-3334
Practice Address - Country:US
Practice Address - Phone:334-288-1868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-30
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALAL46371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009943086Medicaid