Provider Demographics
NPI:1164512208
Name:VICKERS, VICTORIA A (DDS)
Entity Type:Individual
Prefix:DR
First Name:VICTORIA
Middle Name:A
Last Name:VICKERS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40397
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3700
Mailing Address - Country:US
Mailing Address - Phone:210-567-6405
Mailing Address - Fax:210-567-2844
Practice Address - Street 1:7400 BLANCO RD. STE. #100
Practice Address - Street 2:MASTERS DENTAL GROUP
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216
Practice Address - Country:US
Practice Address - Phone:210-349-4424
Practice Address - Fax:210-340-8156
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15678122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX168364101Medicaid
TX168364102OtherMEDICAID
88D990OtherBLUE CROSS BLUE SHIELD
88D990OtherBLUE CROSS BLUE SHIELD
V02464Medicare UPIN