Provider Demographics
NPI:1366584146
Name:VASQUEZ, EDUARDO (DDS)
Entity type:Individual
Prefix:
First Name:EDUARDO
Middle Name:
Last Name:VASQUEZ
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 1:12859 PALM ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-6401
Mailing Address - Country:US
Mailing Address - Phone:714-534-1237
Mailing Address - Fax:
Practice Address - Street 1:501 S IDAHO ST
Practice Address - Street 2:SUITE 120
Practice Address - City:LA HABRA
Practice Address - State:CA
Practice Address - Zip Code:90631-6047
Practice Address - Country:US
Practice Address - Phone:562-690-0400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA498251223D0001X, 1223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223D0001XDental ProvidersDentistDental Public Health
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1366584146Medicaid