Provider Demographics
NPI:1699848002
Name:GURLEY, BRETT ZACKO (RDH)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:ZACKO
Last Name:GURLEY
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:BRETT
Other - Last Name:ZACKO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2309 DARIUS LANE
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-5826
Mailing Address - Country:US
Mailing Address - Phone:703-689-0423
Mailing Address - Fax:
Practice Address - Street 1:1712 CLUBHOUSE RD
Practice Address - Street 2:ZACKO AND ASSOC
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
VA0402002258124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist