Provider Demographics
NPI:1518404615
Name:LOCUST GROVE DENTAL CARE, PC
Entity Type:Organization
Organization Name:LOCUST GROVE DENTAL CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BASIONY
Authorized Official - Middle Name:TAHER
Authorized Official - Last Name:HAGAR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-981-4694
Mailing Address - Street 1:35070 GERMANNA HEIGHTS DR STE B
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:VA
Mailing Address - Zip Code:22508-3108
Mailing Address - Country:US
Mailing Address - Phone:540-399-9841
Mailing Address - Fax:
Practice Address - Street 1:35070 GERMANNA HEIGHTS DR STE B
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:VA
Practice Address - Zip Code:22508-3108
Practice Address - Country:US
Practice Address - Phone:540-399-9841
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-26
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401412257261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center