Provider Demographics
NPI:1316195399
Name:VICKERMAN, WILLIAM EDWIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:EDWIN
Last Name:VICKERMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4980 BARRANCA PKWY
Mailing Address - Street 2:SUITE 206
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-8645
Mailing Address - Country:US
Mailing Address - Phone:949-857-6453
Mailing Address - Fax:949-379-3248
Practice Address - Street 1:4980 BARRANCA PKWY
Practice Address - Street 2:SUITE 206
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-8645
Practice Address - Country:US
Practice Address - Phone:949-857-6453
Practice Address - Fax:949-379-3248
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-03
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA277041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice