Provider Demographics
NPI:1841206042
Name:GORMAN, MICHAEL HASKINS (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:HASKINS
Last Name:GORMAN
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 1:14245P CENTREVILLE SQ
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20121
Mailing Address - Country:US
Mailing Address - Phone:703-830-9110
Mailing Address - Fax:703-830-1632
Practice Address - Street 1:14245P CENTREVILLE SQ
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121
Practice Address - Country:US
Practice Address - Phone:703-830-9110
Practice Address - Fax:703-830-1632
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9178685Medicaid