Provider Demographics
NPI:1255543583
Name:MOLLER, GARY GEORGE (DMD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:GEORGE
Last Name:MOLLER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3690 KING ST. SUITE KL
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22302-1921
Mailing Address - Country:US
Mailing Address - Phone:703-820-0809
Mailing Address - Fax:703-845-1013
Practice Address - Street 1:3690 KING ST. SUITE KL
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22302-1921
Practice Address - Country:US
Practice Address - Phone:703-820-0809
Practice Address - Fax:703-845-1013
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401008167122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist