Healthcare Provider Details

I. General information

NPI: 1902092075
Provider Name (Legal Business Name): ZACK HICHAM MEKOUAR D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2007
Last Update Date: 08/25/2022
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13900 NOBLEWOOD PLZ
WOODBRIDGE VA
22193-1449
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 TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number0401411070
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN1000523
License Number StateDC
# 3
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number13390
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: