Healthcare Provider Details

I. General information

NPI: 1871579789
Provider Name (Legal Business Name): ROBYN ELAINE VICEK DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 JEFFERSON ST
TIFFIN OH
44883-2865
US

IV. Provider business mailing address

205 JEFFERSON ST
TIFFIN OH
44883-2865
US

V. Phone/Fax

Practice location:
  • Phone: 419-447-9242
  • Fax: 419-447-5437
Mailing address:
  • Phone: 419-447-9242
  • Fax: 419-447-5437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number20697
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: