Provider Demographics
NPI:1689873549
Name:ALFONSO-VEGA, EDNA (DMD)
Entity Type:Individual
Prefix:DR
First Name:EDNA
Middle Name:
Last Name:ALFONSO-VEGA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15766 SW 46TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33185-3806
Mailing Address - Country:US
Mailing Address - Phone:305-220-1008
Mailing Address - Fax:
Practice Address - Street 1:4230 SW 152ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33185-5252
Practice Address - Country:US
Practice Address - Phone:305-485-5547
Practice Address - Fax:305-485-5528
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-12
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 132151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice