Provider Demographics
NPI:1366651333
Name:VICENCIO, RAMIR RAMIREZ (DDS)
Entity Type:Individual
Prefix:MR
First Name:RAMIR
Middle Name:RAMIREZ
Last Name:VICENCIO
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 1:12703 PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-4612
Mailing Address - Country:US
Mailing Address - Phone:310-675-3954
Mailing Address - Fax:
Practice Address - Street 1:12703 PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-4612
Practice Address - Country:US
Practice Address - Phone:310-675-3954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD43505122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist