MEDICARE: DR. GARY CHADWICK MARTIN D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223D0001X	Public Health Dentistry	142116	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1421169921	OTHER	UT	DENTAL LICENSE

General Provider Information

NPI Number	:	1144281742
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY CHADWICK MARTIN D.D.S.

Provider Business Mailing Address
First Line	:	5059 MINDA CT
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22304-7772
Country	:	US
Telephone Number	:	703-681-0039
Fax Number	:	703-681-0947

Provider Business Practice Location Address
First Line	:	5111 LEESBURG PIKE
Second Line	:	SKYLINE 5 SUITE 810
City	:	FALLS CHURCH
State	:	VA
Zip	:	22041-3251
Country	:	US
Telephone Number	:	703-681-0039
Fax Number	:	703-681-0947

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/31/2006
Last Update Date	:	03/07/2023

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