Provider Demographics
NPI:1528022910
Name:LA GRUA, DANIEL BRADDOCK (DMD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:BRADDOCK
Last Name:LA GRUA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 W HILL FARM DR
Mailing Address - Street 2:
Mailing Address - City:STAUNTON
Mailing Address - State:VA
Mailing Address - Zip Code:24401-5463
Mailing Address - Country:US
Mailing Address - Phone:540-885-0720
Mailing Address - Fax:
Practice Address - Street 1:1557 COMMERCE RD
Practice Address - Street 2:SUITE 204
Practice Address - City:VERONA
Practice Address - State:VA
Practice Address - Zip Code:24482-9703
Practice Address - Country:US
Practice Address - Phone:540-248-2500
Practice Address - Fax:540-248-2526
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA237197OtherANTHEM BC/BS
1376320OtherUNITED CONCORDIA
VA10544OtherDELTA DENTAL OF VA