Healthcare Provider Details

I. General information

NPI: 1699495580
Provider Name (Legal Business Name): GD VA CDA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2022
Last Update Date: 08/31/2022
Certification Date: 08/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5284 DAWES AVE
ALEXANDRIA VA
22311-1404
US

IV. Provider business mailing address

5284 DAWES AVE
ALEXANDRIA VA
22311-1404
US

V. Phone/Fax

Practice location:
  • Phone: 703-379-6400
  • Fax:
Mailing address:
  • Phone: 703-379-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: CHAD HENDRICKS
Title or Position: CREDENTIALING
Credential:
Phone: 612-859-0444