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General NPI Number Information
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NPI Number | 1780639740
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Entity Type | Individual
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Provider Name | VICTORIA TUCKER OTTERHOLT D.D.S.
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Gender | Female
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Dates
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Enumeration Date | 05/24/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 104 N 15TH ST
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City | MOUNT VERNON
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State | WA
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Zip | 98273-3405
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Country | US
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Telephone | 360-424-9045
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Fax |
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Provider Business Mailing Address
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Address Line | 4002 RIDGE WAY
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City | MOUNT VERNON
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State | WA
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Zip | 98273-9452
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Country | US
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Telephone | 360-424-8804
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 4963
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License Number State | WA
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