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General NPI Number Information
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NPI Number | 1326462367
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Entity Type | Organization
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Legal Business Name | MARCOS GRANDE DDS PLLC
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Dates
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Enumeration Date | 02/11/2014
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Last Update Date | 02/11/2014
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Provider Practice Location Address
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Address Line | 108 ELDEN ST 10
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City | HERNDON
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State | VA
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Zip | 20170-4828
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Country | US
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Telephone | 703-471-7164
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Fax | 703-471-1801
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Provider Business Mailing Address
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Address Line | 108 ELDEN ST 10
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City | HERNDON
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State | VA
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Zip | 20170-4828
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Country | US
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Telephone | 703-471-7164
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Fax | 703-471-1801
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Authorized Official
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Title or Position | DENTIST
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Name | MARCOS GRANDE
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Credential | DDS
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Telephone | 703-471-7164
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 0401411982
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License Number State | VA
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