Basic Information
Provider Information
NPI: 1588086359
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: TERRY
FirstName: EDWARD
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4480 KING ST
Address2:  
City: ALEXANDRIA
State: VA
PostalCode: 223021300
CountryCode: US
TelephoneNumber: 7035355568
FaxNumber: 7035351583
Practice Location
Address1: 2 E GLEBE RD
Address2:  
City: ALEXANDRIA
State: VA
PostalCode: 223052938
CountryCode: US
TelephoneNumber: 7035355568
FaxNumber: 7035351583
Other Information
ProviderEnumerationDate: 01/14/2014
LastUpdateDate: 01/14/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
124Q00000X0402206182VAY Dental ProvidersDental Hygienist 

No ID Information.


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