Provider Demographics
NPI:1417169616
Name:AVERY, VAIDA (DDS)
Entity Type:Individual
Prefix:DR
First Name:VAIDA
Middle Name:
Last Name:AVERY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2036 HORNBLEND ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-4638
Mailing Address - Country:US
Mailing Address - Phone:858-270-6711
Mailing Address - Fax:858-270-8528
Practice Address - Street 1:2036 HORNBLEND ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-4638
Practice Address - Country:US
Practice Address - Phone:858-270-6711
Practice Address - Fax:858-270-8528
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA535751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice