Provider Demographics
NPI:1619033602
Name:WALDEN, VICKIE MARIE (RDA)
Entity Type:Individual
Prefix:MS
First Name:VICKIE
Middle Name:MARIE
Last Name:WALDEN
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:PO BOX 1016
Mailing Address - Street 2:
Mailing Address - City:HAPPY CAMP
Mailing Address - State:CA
Mailing Address - Zip Code:96039-1016
Mailing Address - Country:US
Mailing Address - Phone:530-493-1600
Mailing Address - Fax:530-493-5364
Practice Address - Street 1:64236 SECOND AVENUE
Practice Address - Street 2:
Practice Address - City:HAPPY CAMP
Practice Address - State:CA
Practice Address - Zip Code:96039-1916
Practice Address - Country:US
Practice Address - Phone:530-493-1600
Practice Address - Fax:530-493-5364
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDA59215126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant