Provider Demographics
NPI:1497838981
Name:VICINI, PHILIP ANDREW (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:ANDREW
Last Name:VICINI
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 1:4 DOGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:KENNA
Mailing Address - State:WV
Mailing Address - Zip Code:25248-9666
Mailing Address - Country:US
Mailing Address - Phone:304-984-0052
Mailing Address - Fax:304-984-3140
Practice Address - Street 1:2018 MARTINS BRANCH DRIVE
Practice Address - Street 2:
Practice Address - City:SISSONVILLE
Practice Address - State:WV
Practice Address - Zip Code:25312
Practice Address - Country:US
Practice Address - Phone:303-984-0052
Practice Address - Fax:304-984-3140
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV29581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0133023000Medicaid