Provider Demographics
NPI:1740379460
Name:REYES VICENTE, JORGE (DMD PA)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:
Last Name:REYES VICENTE
Suffix:
Gender:M
Credentials:DMD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1549 S ALAFAYA TRL
Mailing Address - Street 2:SUITE #300
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-8962
Mailing Address - Country:US
Mailing Address - Phone:407-249-0818
Mailing Address - Fax:407-249-0851
Practice Address - Street 1:1549 S ALAFAYA TRL
Practice Address - Street 2:SUITE #300
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-8962
Practice Address - Country:US
Practice Address - Phone:407-249-0818
Practice Address - Fax:407-249-0851
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN165931223G0001X
FLDH18736124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No124Q00000XDental ProvidersDental Hygienist