Provider Demographics
NPI:1447336870
Name:PHILIP A. VICINI DDS.
Entity type:Organization
Organization Name:PHILIP A. VICINI DDS.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:A
Authorized Official - Last Name:VICINI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:304-984-0052
Mailing Address - Street 1:P.O. BOX 13485
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25360-0485
Mailing Address - Country:US
Mailing Address - Phone:304-984-0052
Mailing Address - Fax:304-984-3140
Practice Address - Street 1:1086 MARTINS BRANCH ROAD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25312
Practice Address - Country:US
Practice Address - Phone:304-984-0052
Practice Address - Fax:304-984-3140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22071223G0001X
1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0012784000Medicare ID - Type Unspecified