Provider Demographics
NPI:1356724587
Name:A DENTAL GROUP OF WILLIAM E. VICKERMAN DDS
Entity type:Organization
Organization Name:A DENTAL GROUP OF WILLIAM E. VICKERMAN DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BENSON
Authorized Official - Middle Name:B
Authorized Official - Last Name:DIMARANAN
Authorized Official - Suffix:
Authorized Official - Credentials:BSC, RPHT, RDA, OAP
Authorized Official - Phone:562-202-5741
Mailing Address - Street 1:18000 STUDEBAKER RD STE 365
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-2690
Mailing Address - Country:US
Mailing Address - Phone:562-202-5741
Mailing Address - Fax:
Practice Address - Street 1:18000 STUDEBAKER RD STE 365
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-2690
Practice Address - Country:US
Practice Address - Phone:562-202-5741
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-07
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27704122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty