Healthcare Provider Details

I. General information

NPI: 1457331027
Provider Name (Legal Business Name): DAVID ALLEN VICKERS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 MADISON AVE N
DOUGLAS GA
31533-3126
US

IV. Provider business mailing address

908 MADISON AVE N
DOUGLAS GA
31533-3126
US

V. Phone/Fax

Practice location:
  • Phone: 912-384-4902
  • Fax: 912-384-8820
Mailing address:
  • Phone: 912-384-4902
  • Fax: 912-384-8820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN010714
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: