Provider Demographics
NPI:1033572128
Name:VALLEJO DENTAL PLLC
Entity Type:Organization
Organization Name:VALLEJO DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LONI
Authorized Official - Middle Name:
Authorized Official - Last Name:VALLEJO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:928-277-0142
Mailing Address - Street 1:12075 E STATE ROUTE 69 STE 9
Mailing Address - Street 2:
Mailing Address - City:DEWEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86327-4517
Mailing Address - Country:US
Mailing Address - Phone:928-277-0142
Mailing Address - Fax:928-277-0151
Practice Address - Street 1:12075 E STATE ROUTE 69 STE 9
Practice Address - Street 2:
Practice Address - City:DEWEY
Practice Address - State:AZ
Practice Address - Zip Code:86327-4517
Practice Address - Country:US
Practice Address - Phone:928-277-0142
Practice Address - Fax:928-277-0151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-05
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ70781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty