Provider Demographics
NPI:1114050820
Name:SUSAN E VICKERS DMD PA
Entity Type:Organization
Organization Name:SUSAN E VICKERS DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:VICKERS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD MS
Authorized Official - Phone:410-749-0009
Mailing Address - Street 1:PO BOX 1730
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811
Mailing Address - Country:US
Mailing Address - Phone:410-749-0009
Mailing Address - Fax:410-749-0022
Practice Address - Street 1:11029 RACETRACK RD
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811
Practice Address - Country:US
Practice Address - Phone:410-749-0009
Practice Address - Fax:410-749-0022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000039987Medicaid