Provider Demographics
NPI:1831267947
Name:WICKLUND, LANCE F (DMD)
Entity type:Individual
Prefix:DR
First Name:LANCE
Middle Name:F
Last Name:WICKLUND
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:9723 COPPERTOP LOOP NE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110-3699
Mailing Address - Country:US
Mailing Address - Phone:206-842-6624
Mailing Address - Fax:206-780-5654
Practice Address - Street 1:9723 COPPERTOP LOOP NE
Practice Address - Street 2:SUITE 101
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110
Practice Address - Country:US
Practice Address - Phone:206-842-6624
Practice Address - Fax:206-780-5654
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAWA93201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice