Provider Demographics
NPI:1689845380
Name:DAVID, VICENTE LAICO JR
Entity Type:Individual
Prefix:DR
First Name:VICENTE
Middle Name:LAICO
Last Name:DAVID
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 BEST AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-2704
Mailing Address - Country:US
Mailing Address - Phone:510-569-1740
Mailing Address - Fax:510-569-1740
Practice Address - Street 1:148 BEST AVE
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-2704
Practice Address - Country:US
Practice Address - Phone:510-569-1740
Practice Address - Fax:510-569-1740
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-20
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA456731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice