Healthcare Provider Details

I. General information

NPI: 1073169322
Provider Name (Legal Business Name): GRACE GOODWIN DWYER RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2019
Last Update Date: 09/25/2025
Certification Date: 09/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 SANGAMORE RD STE N100
BETHESDA MD
20816-2558
US

IV. Provider business mailing address

4701 SANGAMORE RD
BETHESDA MD
20816-2508
US

V. Phone/Fax

Practice location:
  • Phone: 914-919-9200
  • Fax:
Mailing address:
  • Phone: 703-501-5736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number3533
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: