Provider Demographics
NPI:1124198296
Name:VICENCIO, CHERYL G (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHERYL
Middle Name:G
Last Name:VICENCIO
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 1:753 SARATOGA AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95129
Mailing Address - Country:US
Mailing Address - Phone:408-255-2222
Mailing Address - Fax:408-255-2280
Practice Address - Street 1:753 SARATOGA AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95129
Practice Address - Country:US
Practice Address - Phone:408-255-2222
Practice Address - Fax:408-255-2280
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39908122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist