Provider Demographics
NPI:1659685014
Name:VITALICH, EDITH HERRERA (RDHAP)
Entity Type:Individual
Prefix:MRS
First Name:EDITH
Middle Name:HERRERA
Last Name:VITALICH
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1607 HIKERS TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91915-1838
Mailing Address - Country:US
Mailing Address - Phone:619-944-2067
Mailing Address - Fax:
Practice Address - Street 1:1607 HIKERS TRAIL DR
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91915-1838
Practice Address - Country:US
Practice Address - Phone:619-944-2067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-27
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA302124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist