Provider Demographics
NPI:1467631549
Name:ZACKOWSKI, STACY L (DDS)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:L
Last Name:ZACKOWSKI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 E PARHAM RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23228-2236
Mailing Address - Country:US
Mailing Address - Phone:804-264-9460
Mailing Address - Fax:804-264-9462
Practice Address - Street 1:2105 E PARHAM RD
Practice Address - Street 2:SUITE 107
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23228-2236
Practice Address - Country:US
Practice Address - Phone:804-264-9460
Practice Address - Fax:804-264-9462
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-25
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401008884122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist