Healthcare Provider Details

I. General information

NPI: 1144281742
Provider Name (Legal Business Name): GARY CHADWICK MARTIN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5111 LEESBURG PIKE SKYLINE 5 SUITE 810
FALLS CHURCH VA
22041-3251
US

IV. Provider business mailing address

5059 MINDA CT
ALEXANDRIA VA
22304-7772
US

V. Phone/Fax

Practice location:
  • Phone: 703-681-0039
  • Fax: 703-681-0947
Mailing address:
  • Phone: 703-681-0039
  • Fax: 703-681-0947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number142116
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: