Provider Demographics
NPI:1184631921
Name:CASIBANG, VICENTE GONZALES (DDS)
Entity Type:Individual
Prefix:DR
First Name:VICENTE
Middle Name:GONZALES
Last Name:CASIBANG
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 1:123 WORTHINGTON STREET
Mailing Address - Street 2:STE 101
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91977
Mailing Address - Country:US
Mailing Address - Phone:619-475-8419
Mailing Address - Fax:619-472-3624
Practice Address - Street 1:123 WORTHINGTON STREET
Practice Address - Street 2:STE 101
Practice Address - City:SPRING VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91977
Practice Address - Country:US
Practice Address - Phone:619-475-8419
Practice Address - Fax:619-472-3624
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA494831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA522496Medicaid
CA522496Medicaid