Provider Demographics
NPI:1972525483
Name:VICKERS, WALTER P JR (DMD)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:P
Last Name:VICKERS
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 MONTLIMAR DR
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36609-1711
Mailing Address - Country:US
Mailing Address - Phone:251-342-0380
Mailing Address - Fax:251-344-3063
Practice Address - Street 1:1200 MONTLIMAR DR
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36609-1711
Practice Address - Country:US
Practice Address - Phone:251-342-0380
Practice Address - Fax:251-344-3063
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5198122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist