Provider Demographics
NPI:1578765723
Name:GRANDE, MARCOS A (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARCOS
Middle Name:A
Last Name:GRANDE
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 1:108 ELDEN ST STE 10
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-4886
Mailing Address - Country:US
Mailing Address - Phone:703-471-7164
Mailing Address - Fax:703-471-1801
Practice Address - Street 1:108 ELDEN ST STE 10
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4886
Practice Address - Country:US
Practice Address - Phone:703-471-7164
Practice Address - Fax:703-471-1801
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014119821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice