Provider Demographics
NPI:1841804911
Name:GROODY, JUSTIN (DDS)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:GROODY
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 1:900 N 24TH ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23223-6412
Mailing Address - Country:US
Mailing Address - Phone:704-575-2007
Mailing Address - Fax:
Practice Address - Street 1:900 N 24TH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-6412
Practice Address - Country:US
Practice Address - Phone:704-575-2007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-04
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04420004071223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics