Provider Demographics
NPI:1508918707
Name:WITCHER, GORDON TIMOTHY (DDS)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:TIMOTHY
Last Name:WITCHER
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 1:11601 IRON BRIDGE RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-1466
Mailing Address - Country:US
Mailing Address - Phone:804-717-5100
Mailing Address - Fax:804-717-5103
Practice Address - Street 1:11601 IRON BRIDGE RD
Practice Address - Street 2:SUITE 204
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23831-1466
Practice Address - Country:US
Practice Address - Phone:804-717-5100
Practice Address - Fax:804-717-5103
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401005310122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA107016OtherANTHEM