Provider Demographics
NPI:1053793653
Name:ASSEFA, MULUALEM TESFAYE (DDS)
Entity type:Individual
Prefix:DR
First Name:MULUALEM
Middle Name:TESFAYE
Last Name:ASSEFA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5622 COLUMBIA PIKE
Mailing Address - Street 2:SUIT 103
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22041-2718
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5570 SILVER HILL RD
Practice Address - Street 2:
Practice Address - City:DISTRICT HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20747-1104
Practice Address - Country:US
Practice Address - Phone:301-202-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-19
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA04014152151223G0001X
MD16016122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCDEN1001790OtherDC DENTAL BOARD
MDMD16016OtherMARYLAND DENTAL BOARD