Provider Demographics
NPI:1164696803
Name:EDWARD L. VINES DDS INC A DENTAL CORPORATION
Entity Type:Organization
Organization Name:EDWARD L. VINES DDS INC A DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:VINES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:408-842-3436
Mailing Address - Street 1:7880 WREN AVE
Mailing Address - Street 2:SUITE B-121
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-4943
Mailing Address - Country:US
Mailing Address - Phone:408-842-3436
Mailing Address - Fax:
Practice Address - Street 1:7880 WREN AVE
Practice Address - Street 2:SUITE B-121
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-4943
Practice Address - Country:US
Practice Address - Phone:408-842-3436
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-14
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA265561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty