Healthcare Provider Details

I. General information

NPI: 1043374317
Provider Name (Legal Business Name): VICKIE LYNN KAISER D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1955 US HIGHWAY 1 S SUITE 100
ST AUGUSTINE FL
32086-3708
US

IV. Provider business mailing address

117 SAINT ANDREWS PLACE DR
ST AUGUSTINE FL
32092-0774
US

V. Phone/Fax

Practice location:
  • Phone: 904-825-5055
  • Fax:
Mailing address:
  • Phone: 904-940-0096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberDN11100
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: