Gary Ellenbogen, D.D.S.

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

5562 Issued in VA

Practice address

8100 Boone Blvd
Vienna, VA 22182-2665

Phone

(703) 734-1095

Fax

(703) 714-9330

NPI assigned

Nov 9, 2006

Reactivated

Sep 11, 2013

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in VA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1163030400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1378857600000",
    "number": "1770653495",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8100 BOONE BLVD",
            "city": "VIENNA",
            "state": "VA",
            "postal_code": "221822665",
            "telephone_number": "703-734-1095",
            "fax_number": "703-714-9330"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "8100 BOONE BLVD",
            "city": "VIENNA",
            "state": "VA",
            "postal_code": "221822665",
            "telephone_number": "703-734-1095",
            "fax_number": "703-714-9330"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ELLENBOGEN",
        "first_name": "GARY",
        "credential": "D.D.S.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-11-09",
        "last_updated": "2013-09-11",
        "deactivation_date": "2010-04-28",
        "reactivation_date": "2013-09-11",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "VA",
            "license": "5562",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Rebecca Elliott
• Kathryn Krueger Ellis, N.P.
• Mary Anne Ellis, JD,PSYD
• Rebecca Ellison, LCSW
• Dania Elmardi

• General Practice Dentistry in Vienna, VA
• Providers in Vienna, VA by specialty
• General Practice Dentistry in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 11, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.