Provider Demographics
NPI:1033468368
Name:VERA, EDWARD LEE (DMD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:LEE
Last Name:VERA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10670 N LOOP DR
Mailing Address - Street 2:
Mailing Address - City:SOCORRO
Mailing Address - State:TX
Mailing Address - Zip Code:79927-4613
Mailing Address - Country:US
Mailing Address - Phone:915-444-2567
Mailing Address - Fax:
Practice Address - Street 1:16946 MARYGOLD AVE STE 101
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-1724
Practice Address - Country:US
Practice Address - Phone:909-355-0385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-31
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61531122300000X
TX29646122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist