Provider Demographics
NPI:1609399385
Name:BRACKET, ZACK (DMD)
Entity Type:Individual
Prefix:
First Name:ZACK
Middle Name:
Last Name:BRACKET
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17015 GAINES RD
Mailing Address - Street 2:
Mailing Address - City:BROAD RUN
Mailing Address - State:VA
Mailing Address - Zip Code:20137-2206
Mailing Address - Country:US
Mailing Address - Phone:571-201-1292
Mailing Address - Fax:
Practice Address - Street 1:254 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:VA
Practice Address - Zip Code:24084-3927
Practice Address - Country:US
Practice Address - Phone:540-674-4191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-25
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC108131223G0001X
VA16093993851223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223G0001XDental ProvidersDentistGeneral Practice