Healthcare Provider Details

I. General information

NPI: 1356482681
Provider Name (Legal Business Name): THOMAS GERARD VACCARO D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 08/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11130 FAIRFAX BLVD
FAIRFAX VA
22030-5035
US

IV. Provider business mailing address

11130 FAIRFAX BLVD
FAIRFAX VA
22030-5035
US

V. Phone/Fax

Practice location:
  • Phone: 703-591-1007
  • Fax:
Mailing address:
  • Phone: 703-591-1007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7446
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: