Provider Demographics
NPI:1265769780
Name:VICKERY, JEANNIE M (DDS)
Entity type:Individual
Prefix:
First Name:JEANNIE
Middle Name:M
Last Name:VICKERY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 W MICHIGAN STREET
Mailing Address - Street 2:DS307B
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5186
Mailing Address - Country:US
Mailing Address - Phone:317-278-3632
Mailing Address - Fax:317-274-2603
Practice Address - Street 1:1121 W MICHIGAN STREET
Practice Address - Street 2:DS307B
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5186
Practice Address - Country:US
Practice Address - Phone:317-278-3632
Practice Address - Fax:317-274-2603
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-04
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007392A1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
12007392AOtherINDIANA DENTAL LICENSE