Provider Demographics
NPI:1609904366
Name:VASQUEZ, JERSON M (DDS)
Entity Type:Individual
Prefix:DR
First Name:JERSON
Middle Name:M
Last Name:VASQUEZ
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 1:16423 LOS COYOTES ST
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-5811
Mailing Address - Country:US
Mailing Address - Phone:951-237-0688
Mailing Address - Fax:
Practice Address - Street 1:270 E. 7TH STREET
Practice Address - Street 2:SUITE 2B
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786
Practice Address - Country:US
Practice Address - Phone:909-985-1211
Practice Address - Fax:909-982-8482
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45535122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA330930763OtherTIN