Provider Demographics
NPI:1043374317
Name:KAISER, VICKIE LYNN (DMD)
Entity type:Individual
Prefix:DR
First Name:VICKIE
Middle Name:LYNN
Last Name:KAISER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 SAINT ANDREWS PLACE DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-0774
Mailing Address - Country:US
Mailing Address - Phone:904-940-0096
Mailing Address - Fax:
Practice Address - Street 1:1955 US HIGHWAY 1 S
Practice Address - Street 2:SUITE 100
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-3708
Practice Address - Country:US
Practice Address - Phone:904-825-5055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN111001223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health