Provider Demographics
NPI:1326463126
Name:VERGARA, EDEGAR (DMD)
Entity Type:Individual
Prefix:DR
First Name:EDEGAR
Middle Name:
Last Name:VERGARA
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 1:4621 CAPITAN DR
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-5447
Mailing Address - Country:US
Mailing Address - Phone:510-585-7977
Mailing Address - Fax:
Practice Address - Street 1:2340 MCKEE RD STE 3
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-1615
Practice Address - Country:US
Practice Address - Phone:669-284-9988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-03
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-024422122300000X
CA63272122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist