Provider Demographics
NPI:1114451150
Name:SCHWARTZ, VICKI MARIE
Entity Type:Individual
Prefix:MISS
First Name:VICKI
Middle Name:MARIE
Last Name:SCHWARTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9950 VALLEY CREEK ROAD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125
Mailing Address - Country:US
Mailing Address - Phone:612-850-5813
Mailing Address - Fax:
Practice Address - Street 1:9950 VALLEY CREEK ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125
Practice Address - Country:US
Practice Address - Phone:612-850-5813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA84281223S0112X, 126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No126800000XDental ProvidersDental Assistant