Provider Demographics
NPI:1043456221
Name:VAZQUEZ, DESIREE (DA)
Entity Type:Individual
Prefix:MISS
First Name:DESIREE
Middle Name:
Last Name:VAZQUEZ
Suffix:
Gender:F
Credentials:DA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W. SHAW AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-4690
Mailing Address - Country:US
Mailing Address - Phone:559-458-1363
Mailing Address - Fax:
Practice Address - Street 1:200 W SHAW AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-3684
Practice Address - Country:US
Practice Address - Phone:559-458-1363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-18
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant