Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 49825 | CA |
N | 1223D0001X | Dental Public Health | 49825 | CA |
N | 1223G0001X | General Practice | 49825 | CA |
N | 213EG0000X | General Practice | 49825 | CA |
NPI | 1366584146 |
---|---|
Provider Name | Eduardo Vasquez |
First Address | Garden Grove, CA 92840-6401 |
Second Address | La Habra, CA 90631-6047 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/02/2007 |
Last Update Date | 01/06/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1366584146 | (05) | CA |