Provider Demographics
NPI:1316146616
Name:MIRAMON, VICENTE OCTAVIO (DDS)
Entity type:Individual
Prefix:DR
First Name:VICENTE
Middle Name:OCTAVIO
Last Name:MIRAMON
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 1:276 CHURCH AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-2729
Mailing Address - Country:US
Mailing Address - Phone:619-422-4446
Mailing Address - Fax:619-498-1690
Practice Address - Street 1:276 CHURCH AVE
Practice Address - Street 2:SUITE C
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-2729
Practice Address - Country:US
Practice Address - Phone:619-422-4446
Practice Address - Fax:619-498-1690
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-16
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB31669122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist