Provider Demographics
NPI:1225004195
Name:VICKERS, SUSAN ELLEN (DMD,MS)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:ELLEN
Last Name:VICKERS
Suffix:
Gender:F
Credentials:DMD,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29913 WINCHESTER CT
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-2401
Mailing Address - Country:US
Mailing Address - Phone:410-334-6632
Mailing Address - Fax:
Practice Address - Street 1:6512A DEER POINTE DR
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-1669
Practice Address - Country:US
Practice Address - Phone:410-749-0009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD125431223P0221X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223P0221XDental ProvidersDentistPediatric Dentistry