Provider Demographics
NPI:1073686499
Name:ZACKO, GEORGE BERNARD (DDS)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:BERNARD
Last Name:ZACKO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2403 BLACK CAP LANE
Mailing Address - Street 2:GEORGE ZACKO
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190
Mailing Address - Country:US
Mailing Address - Phone:703-620-9368
Mailing Address - Fax:
Practice Address - Street 1:1712 CLUBHOUSE RD
Practice Address - Street 2:SUITE 106
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190
Practice Address - Country:US
Practice Address - Phone:703-471-6600
Practice Address - Fax:703-471-1675
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401002948122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist