Provider Demographics
NPI:1760050736
Name:DEREK L VAJDA DDS MD INC
Entity Type:Organization
Organization Name:DEREK L VAJDA DDS MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:LUDOVIT
Authorized Official - Last Name:VAJDA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:219-789-8308
Mailing Address - Street 1:1541 CENTINELA AVE
Mailing Address - Street 2:UNIT 105
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-3222
Mailing Address - Country:US
Mailing Address - Phone:219-789-8308
Mailing Address - Fax:
Practice Address - Street 1:501 S GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801-3840
Practice Address - Country:US
Practice Address - Phone:626-570-1818
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty