Provider Demographics
NPI:1700388014
Name:VICKERS, LUKE DAVID (DDS)
Entity type:Individual
Prefix:
First Name:LUKE
Middle Name:DAVID
Last Name:VICKERS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 572
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92033-0572
Mailing Address - Country:US
Mailing Address - Phone:760-859-6032
Mailing Address - Fax:
Practice Address - Street 1:3405 VICKSBURG LN N STE 120
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-1370
Practice Address - Country:US
Practice Address - Phone:760-859-6032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-02
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT-29601223S0112X
MND151591223S0112X
IL018.0020731223S0112X
390200000X
CA1035241223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program