Provider Demographics
NPI:1215021464
Name:IMMEL, VICTOR D (DMD)
Entity Type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:D
Last Name:IMMEL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 W YAKIMA AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-2943
Mailing Address - Country:US
Mailing Address - Phone:509-457-5387
Mailing Address - Fax:509-457-6580
Practice Address - Street 1:1514 W YAKIMA AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-2943
Practice Address - Country:US
Practice Address - Phone:509-457-5387
Practice Address - Fax:509-457-6580
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA69211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA128266OtherLABOR AND INDUSTRIES
WAIM1280OtherBLUE SHIELD
WA5032222OtherDSHS
WA9643Other9643
WA91-1981595OtherTIN