Provider Demographics
NPI:1659446961
Name:GERALD, GLENN DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:DAVID
Last Name:GERALD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11420 MEADOW LAKE CT
Mailing Address - Street 2:
Mailing Address - City:OAKTON
Mailing Address - State:VA
Mailing Address - Zip Code:22124-1157
Mailing Address - Country:US
Mailing Address - Phone:703-264-0924
Mailing Address - Fax:703-264-0479
Practice Address - Street 1:2573 CHAIN BRIDGE RD
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22181-5576
Practice Address - Country:US
Practice Address - Phone:703-281-0041
Practice Address - Fax:703-281-0088
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010060151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice