Provider Demographics
NPI:1619060118
Name:VITAL, JORGE E (DDS)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:E
Last Name:VITAL
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 1:102 E. 4TH ST
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701
Mailing Address - Country:US
Mailing Address - Phone:714-558-1464
Mailing Address - Fax:714-558-2971
Practice Address - Street 1:102 E. 4TH ST
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701
Practice Address - Country:US
Practice Address - Phone:714-558-1464
Practice Address - Fax:714-558-2971
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49701122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist