Provider Demographics
NPI:1679548010
Name:VANDERVORT, GENE ALLEN JR (DDS/MD)
Entity type:Individual
Prefix:DR
First Name:GENE
Middle Name:ALLEN
Last Name:VANDERVORT
Suffix:JR
Gender:M
Credentials:DDS/MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44340 PREMIER PLAZA
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-5074
Mailing Address - Country:US
Mailing Address - Phone:703-729-8700
Mailing Address - Fax:703-729-5300
Practice Address - Street 1:44340 PREMIER PLAZA
Practice Address - Street 2:SUITE 100
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-5074
Practice Address - Country:US
Practice Address - Phone:703-729-8700
Practice Address - Fax:703-729-5300
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101102662204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery