Healthcare Provider Details

I. General information

NPI: 1437865342
Provider Name (Legal Business Name): LEESBURG DENTAL AND ORTHODONTICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2023
Last Update Date: 01/24/2023
Certification Date: 01/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 ROBINSON MILL PLZ SE STE 108
LEESBURG VA
20175-4797
US

IV. Provider business mailing address

9616 GEORGETOWN PIKE
GREAT FALLS VA
22066-2638
US

V. Phone/Fax

Practice location:
  • Phone: 703-347-1282
  • Fax:
Mailing address:
  • Phone: 703-347-1282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. ZACK HICHAM MEKOUAR
Title or Position: PRESIDENT
Credential: DDS
Phone: 703-347-1282