Provider Demographics
NPI:1487709069
Name:TICKNOR, VERNE E (DDS)
Entity type:Individual
Prefix:DR
First Name:VERNE
Middle Name:E
Last Name:TICKNOR
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 1:900 S BAILEY AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-9701
Mailing Address - Country:US
Mailing Address - Phone:269-637-1281
Mailing Address - Fax:269-639-1440
Practice Address - Street 1:900 S BAILEY AVE
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-9701
Practice Address - Country:US
Practice Address - Phone:269-637-1281
Practice Address - Fax:269-639-1440
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010100351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice