Healthcare Provider Details

I. General information

NPI: 1245382274
Provider Name (Legal Business Name): ZAVISLAK AND PORTER DDS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 CENTRAL PARK BLVD SUITE 200
FREDERICKSBURG VA
22401-4940
US

IV. Provider business mailing address

1340 CENTRAL PARK BLVD SUITE 200
FREDERICKSBURG VA
22401-4940
US

V. Phone/Fax

Practice location:
  • Phone: 540-786-9559
  • Fax: 540-786-1119
Mailing address:
  • Phone: 540-786-9559
  • Fax: 540-786-1119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4018811
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4018218
License Number StateVA

VIII. Authorized Official

Name: DR. ROBERT LEE ZAVISLAK
Title or Position: PRESIDENT
Credential: DDS
Phone: 540-786-9559