Provider Demographics
NPI:1144281742
Name:MARTIN, GARY CHADWICK (DDS)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:CHADWICK
Last Name:MARTIN
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 1:5059 MINDA CT
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-7772
Mailing Address - Country:US
Mailing Address - Phone:703-681-0039
Mailing Address - Fax:703-681-0947
Practice Address - Street 1:5111 LEESBURG PIKE
Practice Address - Street 2:SKYLINE 5 SUITE 810
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22041-3251
Practice Address - Country:US
Practice Address - Phone:703-681-0039
Practice Address - Fax:703-681-0947
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1421161223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1421169921OtherDENTAL LICENSE
UT1421169921OtherDENTAL LICENSE