Healthcare Provider Details

I. General information

NPI: 1689910556
Provider Name (Legal Business Name): GROVE DENTAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2012
Last Update Date: 12/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 OSAGE ST SUITE NUMBER 402
ALEXANDRIA VA
22302-2607
US

IV. Provider business mailing address

1707 OSAGE ST SUITE NUMBER 402
ALEXANDRIA VA
22302-2607
US

V. Phone/Fax

Practice location:
  • Phone: 703-578-1700
  • Fax:
Mailing address:
  • Phone: 703-578-1700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401007713
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number0401412357
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401413405
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number0401413657
License Number StateVA

VIII. Authorized Official

Name: DR. MAQSOOD A CHAUDHRY
Title or Position: OWNER
Credential: DDS
Phone: 703-578-0000