Provider Demographics
NPI:1326462367
Name:MARCOS GRANDE DDS PLLC
Entity Type:Organization
Organization Name:MARCOS GRANDE DDS PLLC
Other - Org Name:EXPRESS SMILES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MARCOS
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANDE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-471-7164
Mailing Address - Street 1:108 ELDEN ST
Mailing Address - Street 2:10
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-4828
Mailing Address - Country:US
Mailing Address - Phone:703-471-7164
Mailing Address - Fax:703-471-1801
Practice Address - Street 1:108 ELDEN ST
Practice Address - Street 2:10
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4828
Practice Address - Country:US
Practice Address - Phone:703-471-7164
Practice Address - Fax:703-471-1801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-11
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014119821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty