Healthcare Provider Details

I. General information

NPI: 1588086359
Provider Name (Legal Business Name): EDWARD TERRY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2014
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 E GLEBE RD
ALEXANDRIA VA
22305-2938
US

IV. Provider business mailing address

1769 LEXINGTON AVE N # 104
ROSEVILLE MN
55113-6522
US

V. Phone/Fax

Practice location:
  • Phone: 703-535-5568
  • Fax: 703-535-1583
Mailing address:
  • Phone:
  • Fax: 703-535-1583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number0402206182
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code125K00000X
TaxonomyAdvanced Practice Dental Therapist
License NumberD180
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code125J00000X
TaxonomyDental Therapist
License NumberD180
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: