Provider Demographics
NPI:1174250781
Name:VARGAS, JOSE DANIEL (DMD)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:DANIEL
Last Name:VARGAS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 SYLVESTER CT
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31768-2634
Mailing Address - Country:US
Mailing Address - Phone:229-529-3216
Mailing Address - Fax:
Practice Address - Street 1:138 OAKLAND PKWY
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:GA
Practice Address - Zip Code:31763-7200
Practice Address - Country:US
Practice Address - Phone:229-529-3216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-03
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1227721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty