Provider Demographics
NPI:1235453325
Name:LLAVERIAS, VICKI (RDA)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:
Last Name:LLAVERIAS
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-5716
Mailing Address - Country:US
Mailing Address - Phone:415-473-5450
Mailing Address - Fax:415-473-5460
Practice Address - Street 1:411 4TH ST
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-5716
Practice Address - Country:US
Practice Address - Phone:415-473-5450
Practice Address - Fax:415-473-5460
Is Sole Proprietor?:No
Enumeration Date:2010-03-18
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39927126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant