Provider Demographics
NPI:1114377652
Name:MAGOONBARKER, VICTORIA (HL)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:MAGOONBARKER
Suffix:
Gender:F
Credentials:HL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 E 47TH ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98404-2834
Mailing Address - Country:US
Mailing Address - Phone:206-849-5877
Mailing Address - Fax:
Practice Address - Street 1:527 BARNES BLVD
Practice Address - Street 2:
Practice Address - City:JOINT BASE LEWIS MCCHORD
Practice Address - State:WA
Practice Address - Zip Code:98438-1304
Practice Address - Country:US
Practice Address - Phone:253-982-5505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-15
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60316932124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist