Provider Demographics
NPI:1194044933
Name:WEISS, GARY JOHN (DDS)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:JOHN
Last Name:WEISS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9854 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-3908
Mailing Address - Country:US
Mailing Address - Phone:703-278-8866
Mailing Address - Fax:703-278-9089
Practice Address - Street 1:9854 MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-3908
Practice Address - Country:US
Practice Address - Phone:703-278-8866
Practice Address - Fax:703-278-9089
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-19
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401-0060041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice