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General NPI Number Information
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NPI Number | 1518404615
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Entity Type | Organization
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Legal Business Name | LOCUST GROVE DENTAL CARE, PC
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Dates
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Enumeration Date | 01/26/2017
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Last Update Date | 01/26/2017
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Provider Practice Location Address
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Address Line | 35070 GERMANNA HEIGHTS DR STE B
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City | LOCUST GROVE
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State | VA
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Zip | 22508-3108
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Country | US
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Telephone | 540-399-9841
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Fax |
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Provider Business Mailing Address
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Address Line | 35070 GERMANNA HEIGHTS DR STE B
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City | LOCUST GROVE
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State | VA
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Zip | 22508-3108
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Country | US
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Telephone | 540-399-9841
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. BASIONY TAHER HAGAR
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Credential | DDS
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Telephone | 703-981-4694
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 0401412257
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License Number State | VA
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