Provider Demographics
NPI:1790198547
Name:GROSSMAN, MALLORY (DDS)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:GROSSMAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 CLARENDON BLVD
Mailing Address - Street 2:APT 1311
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22201-3332
Mailing Address - Country:US
Mailing Address - Phone:518-588-0198
Mailing Address - Fax:
Practice Address - Street 1:1600 WILSON BLVD STE 620
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22209-2596
Practice Address - Country:US
Practice Address - Phone:703-524-0288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-10
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014149461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice