Provider Demographics
NPI:1164880399
Name:VICE, ERICA
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:VICE
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 1:313 S LAKEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-2815
Mailing Address - Country:US
Mailing Address - Phone:813-653-6271
Mailing Address - Fax:
Practice Address - Street 1:313 S LAKEWOOD DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-2815
Practice Address - Country:US
Practice Address - Phone:813-653-6271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-02
Last Update Date:2021-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN25724122300000X, 1223P0221X
RIDEN032981223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist