Provider Demographics
NPI:1639467780
Name:DULUC VEGA, PABLO (DDS, CAGS)
Entity Type:Individual
Prefix:DR
First Name:PABLO
Middle Name:
Last Name:DULUC VEGA
Suffix:
Gender:M
Credentials:DDS, CAGS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E NEWTON ST FL 7
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2308
Mailing Address - Country:US
Mailing Address - Phone:617-638-4636
Mailing Address - Fax:
Practice Address - Street 1:100 E NEWTON ST FL 7
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2308
Practice Address - Country:US
Practice Address - Phone:617-638-4636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN207831223E0200X
MADL113181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No1223G0001XDental ProvidersDentistGeneral Practice