MEDICARE: DR. JEFFREY CHRISTIAN ZACKERU DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	10662	NC

General Provider Information

NPI Number	:	1073042065
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY CHRISTIAN ZACKERU DMD

Provider Business Mailing Address
First Line	:	960 FOREST GROVE DR
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27104-1445
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	481 SHEPHERD ST
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-1627
Country	:	US
Telephone Number	:	336-768-8850
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2017
Last Update Date	:	06/05/2017

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