Healthcare Provider Details

I. General information

NPI: 1114477650
Provider Name (Legal Business Name): GRISELDA LOPEZ RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2016
Last Update Date: 10/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2712 JEFFERSON DAVIS HWY #210
STAFFORD VA
22554-1769
US

IV. Provider business mailing address

16 PURI LN
STAFFORD VA
22554-8201
US

V. Phone/Fax

Practice location:
  • Phone: 703-473-0925
  • Fax:
Mailing address:
  • Phone: 540-720-8630
  • Fax: 540-720-8632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number0402206670
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: