Healthcare Provider Details

I. General information

NPI: 1699477463
Provider Name (Legal Business Name): GD VA GDA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2023
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 TYSONS BLVD STE 120
MC LEAN VA
22102-4882
US

IV. Provider business mailing address

1600 TYSONS BLVD STE 120
MC LEAN VA
22102-4882
US

V. Phone/Fax

Practice location:
  • Phone: 703-527-1020
  • Fax:
Mailing address:
  • Phone: 703-448-1020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
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