Provider Demographics
NPI:1003153461
Name:VASILIAUSKAS, EDITA (DDS)
Entity Type:Individual
Prefix:MRS
First Name:EDITA
Middle Name:
Last Name:VASILIAUSKAS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2448 GUERNEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-4175
Mailing Address - Country:US
Mailing Address - Phone:707-579-2808
Mailing Address - Fax:
Practice Address - Street 1:2448 GUERNEVILLE RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-4175
Practice Address - Country:US
Practice Address - Phone:707-579-2808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-04
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52695122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist