Provider Demographics
NPI:1699262634
Name:EDEGAR VERGARA, DMD INC
Entity type:Organization
Organization Name:EDEGAR VERGARA, DMD INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:EDEGAR
Authorized Official - Middle Name:
Authorized Official - Last Name:VERGARA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:669-284-9988
Mailing Address - Street 1:2340 MCKEE RD STE 3
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95116-1615
Mailing Address - Country:US
Mailing Address - Phone:669-284-9988
Mailing Address - Fax:
Practice Address - Street 1:2340 MCKEE RD STE 3
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-1615
Practice Address - Country:US
Practice Address - Phone:669-284-9988
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-16
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental