Healthcare Provider Details

I. General information

NPI: 1164512208
Provider Name (Legal Business Name): VICTORIA A. VICKERS DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 01/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7400 BLANCO RD. STE. #100 MASTERS DENTAL GROUP
SAN ANTONIO TX
78216
US

IV. Provider business mailing address

PO BOX 40397
SAN ANTONIO TX
78229-3700
US

V. Phone/Fax

Practice location:
  • Phone: 210-349-4424
  • Fax: 210-340-8156
Mailing address:
  • Phone: 210-567-6405
  • Fax: 210-567-2844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number15678
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: