Provider Demographics
NPI:1083353452
Name:VAZQUEZ, SHANEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHANEL
Middle Name:
Last Name:VAZQUEZ
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20984 UPTOWN AVE APT 503
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33428-6584
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3003 W YAMATO RD STE C5
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33434-5337
Practice Address - Country:US
Practice Address - Phone:561-998-0727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-02
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN28877122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice