Basic Information
| Provider Information | |||||||||
| NPI: | 1114449402 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORMAN | ||||||||
| FirstName: | EDINA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1612 HUGUENOT RD | ||||||||
| Address2: | |||||||||
| City: | MIDLOTHIAN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8047949789 | ||||||||
| FaxNumber: | 8044191059 | ||||||||
| Practice Location | |||||||||
| Address1: | 6353 MECHANICSVILLE TPKE | ||||||||
| Address2: | |||||||||
| City: | MECHANICSVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8047303400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2017 | ||||||||
| LastUpdateDate: | 08/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 018.002032 | IL | Y | Dental Providers | Dentist | General Practice |
No ID Information.