Provider Demographics
NPI:1184842908
Name:VALLEJO, SERGIO RAMIRO (DMD)
Entity Type:Individual
Prefix:DR
First Name:SERGIO
Middle Name:RAMIRO
Last Name:VALLEJO
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 1:4335 HIGHLAND PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-1671
Mailing Address - Country:US
Mailing Address - Phone:863-648-0046
Mailing Address - Fax:863-647-1410
Practice Address - Street 1:4335 HIGHLAND PARK BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-1671
Practice Address - Country:US
Practice Address - Phone:863-648-0046
Practice Address - Fax:863-647-1410
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFLDN00012087122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist