Provider Demographics
NPI:1629148572
Name:LEGUM, MARTY (DDS)
Entity Type:Individual
Prefix:
First Name:MARTY
Middle Name:
Last Name:LEGUM
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 1:1500 BELLEVIEW BLVD.
Mailing Address - Street 2:1500
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22307
Mailing Address - Country:US
Mailing Address - Phone:706-768-4777
Mailing Address - Fax:706-768-3018
Practice Address - Street 1:1500 BELLEVIEW BLVD.
Practice Address - Street 2:1500
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22307
Practice Address - Country:US
Practice Address - Phone:706-768-4777
Practice Address - Fax:706-768-3018
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA73321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice