Provider Demographics
NPI:1699477463
Name:GD VA GDA PLLC
Entity type:Organization
Organization Name:GD VA GDA PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDRICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-859-0444
Mailing Address - Street 1:1600 TYSONS BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-4882
Mailing Address - Country:US
Mailing Address - Phone:703-448-1020
Mailing Address - Fax:
Practice Address - Street 1:1600 TYSONS BLVD STE 120
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-4882
Practice Address - Country:US
Practice Address - Phone:703-527-1020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-17
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty