Provider Demographics
NPI:1093913832
Name:VIGIL, SUZAN K (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUZAN
Middle Name:K
Last Name:VIGIL
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 1:2428 SANTA MONICA BLVD
Mailing Address - Street 2:#102
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2045
Mailing Address - Country:US
Mailing Address - Phone:310-315-1142
Mailing Address - Fax:310-315-0640
Practice Address - Street 1:2428 SANTA MONICA BLVD
Practice Address - Street 2:#102
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2045
Practice Address - Country:US
Practice Address - Phone:310-315-1142
Practice Address - Fax:310-315-0640
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA031726122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist