Healthcare Provider Details

I. General information

NPI: 1477194421
Provider Name (Legal Business Name): VICKI LEE GIACOMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2019
Last Update Date: 10/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7520 TOTEM BEACH RD
TULALIP WA
98271-6160
US

IV. Provider business mailing address

7520 TOTEM BEACH RD
TULALIP WA
98271-6160
US

V. Phone/Fax

Practice location:
  • Phone: 360-716-4511
  • Fax:
Mailing address:
  • Phone: 360-716-4511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number60897967
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: