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General NPI Number Information
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NPI Number | 1578765723
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Entity Type | Individual
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Provider Name | MARCOS A GRANDE DDS
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Gender | Male
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Dates
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Enumeration Date | 06/01/2007
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Last Update Date | 02/20/2018
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Provider Practice Location Address
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Address Line | 108 ELDEN ST STE 10
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City | HERNDON
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State | VA
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Zip | 20170-4886
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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 STE 10
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City | HERNDON
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State | VA
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Zip | 20170-4886
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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 |
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Name |
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Credential |
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Telephone |
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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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