Provider Demographics
NPI:1477194421
Name:GIACOMAN, VICKI LEE
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:LEE
Last Name:GIACOMAN
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 1:7520 TOTEM BEACH RD
Mailing Address - Street 2:
Mailing Address - City:TULALIP
Mailing Address - State:WA
Mailing Address - Zip Code:98271-6160
Mailing Address - Country:US
Mailing Address - Phone:360-716-4511
Mailing Address - Fax:
Practice Address - Street 1:7520 TOTEM BEACH RD
Practice Address - Street 2:
Practice Address - City:TULALIP
Practice Address - State:WA
Practice Address - Zip Code:98271-6160
Practice Address - Country:US
Practice Address - Phone:360-716-4511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-01
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60897967126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant