Provider Demographics
NPI:1124393954
Name:JORGE VASQUEZ-GARCIA DDS DENTAL CORP
Entity Type:Organization
Organization Name:JORGE VASQUEZ-GARCIA DDS DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:VASQUEZ-GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:707-536-3685
Mailing Address - Street 1:750 STONY POINT RD STE A130
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-6863
Mailing Address - Country:US
Mailing Address - Phone:707-536-3685
Mailing Address - Fax:
Practice Address - Street 1:750 STONY POINT RD STE A130
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-6863
Practice Address - Country:US
Practice Address - Phone:707-536-3685
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-12
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53286261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1598831091Medicare PIN