Provider Demographics
NPI:1538867007
Name:GILLEN, GRACE I
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:I
Last Name:GILLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13007 PINEY GLADE RD
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-2956
Mailing Address - Country:US
Mailing Address - Phone:571-296-6978
Mailing Address - Fax:
Practice Address - Street 1:1890 PRESTON WHITE DR STE 200
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-5430
Practice Address - Country:US
Practice Address - Phone:703-437-8811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-23
Last Update Date:2025-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014193791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice