Individual
JEANNIE M VICKERY
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
DDS
Contact information
Practice address
1121 W MICHIGAN STREET, DS307B, INDIANAPOLIS, IN 46202-5186
(317) 278-3632
(317) 274-2603
Mailing address
1121 W MICHIGAN STREET, DS307B, INDIANAPOLIS, IN 46202-5186
(317) 278-3632
(317) 274-2603
Taxonomy
Speciality
Code
Description
License number
State
1223P0700X
Prosthodontics
Primary
12007392A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
12007392A
INDIANA DENTAL LICENSE
—
Enumeration date
11/04/2009
Last updated
11/03/2016
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