Provider Demographics
NPI:1114297785
Name:VASQUEZ DENTAL CORPORATION
Entity type:Organization
Organization Name:VASQUEZ DENTAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE ANGELO
Authorized Official - Middle Name:RAGON
Authorized Official - Last Name:VASQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:760-724-1102
Mailing Address - Street 1:2420 VISTA WAY STE 210
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054-6190
Mailing Address - Country:US
Mailing Address - Phone:760-724-1102
Mailing Address - Fax:760-724-1471
Practice Address - Street 1:2420 VISTA WAY STE 210
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054
Practice Address - Country:US
Practice Address - Phone:760-724-1102
Practice Address - Fax:760-724-1471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-12
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA540361223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD54036Medicaid
CA1770613598OtherNPI TYPE I