Provider Demographics
NPI:1689910556
Name:GROVE DENTAL CLINIC
Entity Type:Organization
Organization Name:GROVE DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAQSOOD
Authorized Official - Middle Name:A
Authorized Official - Last Name:CHAUDHRY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-578-0000
Mailing Address - Street 1:1707 OSAGE ST
Mailing Address - Street 2:SUITE NUMBER 402
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22302-2607
Mailing Address - Country:US
Mailing Address - Phone:703-578-1700
Mailing Address - Fax:
Practice Address - Street 1:1707 OSAGE ST
Practice Address - Street 2:SUITE NUMBER 402
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22302-2607
Practice Address - Country:US
Practice Address - Phone:703-578-1700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-21
Last Update Date:2012-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401007713122300000X
VA04014123571223E0200X
VA04014134051223G0001X
VA04014136571223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty