Provider Demographics
NPI:1245382274
Name:ZAVISLAK AND PORTER DDS, PC
Entity Type:Organization
Organization Name:ZAVISLAK AND PORTER DDS, PC
Other - Org Name:CENTRAL PARK DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:ZAVISLAK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:540-786-9559
Mailing Address - Street 1:1340 CENTRAL PARK BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-4940
Mailing Address - Country:US
Mailing Address - Phone:540-786-9559
Mailing Address - Fax:540-786-1119
Practice Address - Street 1:1340 CENTRAL PARK BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-4940
Practice Address - Country:US
Practice Address - Phone:540-786-9559
Practice Address - Fax:540-786-1119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA40182181223G0001X
VA40188111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty