Provider Demographics
NPI:1083835367
Name:VACCA, RICHARD S (DDS)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:S
Last Name:VACCA
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 1:5921 HARBOUR LN
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-2158
Mailing Address - Country:US
Mailing Address - Phone:804-739-9191
Mailing Address - Fax:804-739-7764
Practice Address - Street 1:5921 HARBOUR LN
Practice Address - Street 2:SUITE 400
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-2158
Practice Address - Country:US
Practice Address - Phone:804-739-9191
Practice Address - Fax:804-739-7764
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010074591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice