Provider Demographics
NPI:1609308683
Name:AROCHA, GUSTAVO MANUEL JR (DDS)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:MANUEL
Last Name:AROCHA
Suffix:JR
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 1:4379 RIDGEWOOD CENTER DR STE 102
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-8323
Mailing Address - Country:US
Mailing Address - Phone:703-680-7950
Mailing Address - Fax:
Practice Address - Street 1:4379 RIDGEWOOD CENTER DR STE 102
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192
Practice Address - Country:US
Practice Address - Phone:703-680-7950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-30
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA04014161031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program