Provider Demographics
NPI:1619980745
Name:NOONAN, VIKKI LOUISE (DMD, DMSC)
Entity Type:Individual
Prefix:
First Name:VIKKI
Middle Name:LOUISE
Last Name:NOONAN
Suffix:
Gender:F
Credentials:DMD, DMSC
Other - Prefix:
Other - First Name:VIKKI
Other - Middle Name:LOUISE
Other - Last Name:VAUGHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD, DMSC
Mailing Address - Street 1:133 BROOKLINE AVE
Mailing Address - Street 2:6TH FLOOR;HARVARD VANGUARD MEDICAL ASSOC.;DEPT OF PATH.
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-3904
Mailing Address - Country:US
Mailing Address - Phone:617-421-2844
Mailing Address - Fax:617-421-2423
Practice Address - Street 1:133 BROOKLINE AVE
Practice Address - Street 2:6TH FLOOR;HARVARD VANGUARD MEDICAL ASSOC.;DEPT OF PATH.
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-3904
Practice Address - Country:US
Practice Address - Phone:617-421-2844
Practice Address - Fax:617-421-2423
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA195191223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0203718Medicaid
AA27554OtherHARVARD PILGRIM
X09107OtherBLUE CROSS
MA0203718Medicaid
X09107OtherBLUE CROSS