Provider Demographics
NPI:1982825410
Name:IVY, GREGORY MARTIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:MARTIN
Last Name:IVY
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 1:8342 TRAFORD LANE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22152-1638
Mailing Address - Country:US
Mailing Address - Phone:703-644-5955
Mailing Address - Fax:703-644-1337
Practice Address - Street 1:8342 TRAFORD LANE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22152-1638
Practice Address - Country:US
Practice Address - Phone:703-644-5955
Practice Address - Fax:703-644-1337
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010056141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice