Provider Demographics
NPI:1770653495
Name:ELLENBOGEN, GARY (DDS)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:ELLENBOGEN
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 1:8100 BOONE BLVD
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2665
Mailing Address - Country:US
Mailing Address - Phone:703-734-1095
Mailing Address - Fax:703-714-9330
Practice Address - Street 1:8100 BOONE BLVD
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-2665
Practice Address - Country:US
Practice Address - Phone:703-734-1095
Practice Address - Fax:703-714-9330
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2013-09-11
Deactivation Date:2010-04-28
Deactivation Code:
Reactivation Date:2013-09-11
Provider Licenses
StateLicense IDTaxonomies
VA55621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice