Provider Demographics
NPI:1164544573
Name:DE LA VEGA, EDGARDO A (DDS)
Entity Type:Individual
Prefix:
First Name:EDGARDO
Middle Name:A
Last Name:DE LA VEGA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22114 ROSCOE BLVD
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91304-3838
Mailing Address - Country:US
Mailing Address - Phone:818-348-8713
Mailing Address - Fax:
Practice Address - Street 1:22114 ROSCOE BLVD
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91304-3838
Practice Address - Country:US
Practice Address - Phone:818-348-8713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA223361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice