Provider Demographics
NPI:1548244106
Name:VARGAS, DOUGLAS MAYOVANE (DDS)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:MAYOVANE
Last Name:VARGAS
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 1:984 SHERIDAN AVE
Mailing Address - Street 2:APT 3A
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10456-6330
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:713 SAINT NICHOLAS AVE
Practice Address - Street 2:GROUND FL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031-4905
Practice Address - Country:US
Practice Address - Phone:212-234-6960
Practice Address - Fax:212-234-6982
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0502071122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02395471Medicaid