Provider Demographics
NPI:1407875958
Name:GUILLERMO VEGA, LUIS (DDS)
Entity type:Individual
Prefix:DR
First Name:LUIS
Middle Name:
Last Name:GUILLERMO VEGA
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 1:6520 226TH PLACE SE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027
Mailing Address - Country:US
Mailing Address - Phone:425-477-7723
Mailing Address - Fax:425-477-7784
Practice Address - Street 1:6520 226TH PLACE SE
Practice Address - Street 2:SUITE 205
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027
Practice Address - Country:US
Practice Address - Phone:425-477-7723
Practice Address - Fax:425-477-7784
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS9751204E00000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00323221OtherRAILROAD MEDICARE
FL0762091-00Medicaid
FLP00323221OtherRAILROAD MEDICARE
FLP00323221OtherRAILROAD MEDICARE
FLU7886ZMedicare PIN