Provider Demographics
NPI:1942233887
Name:GLADSTONE, MYRON DAVID (DDS)
Entity type:Individual
Prefix:DR
First Name:MYRON
Middle Name:DAVID
Last Name:GLADSTONE
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 1:5318 PROVIDENCE RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-4102
Mailing Address - Country:US
Mailing Address - Phone:757-424-3657
Mailing Address - Fax:757-424-3451
Practice Address - Street 1:5318 PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-4102
Practice Address - Country:US
Practice Address - Phone:757-424-3657
Practice Address - Fax:757-424-3451
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA44181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA817549OtherUNITED CONCORDIA
CA094701OtherANTHEM BC/BS