Provider Demographics
NPI:1821614876
Name:DAVID K. VAZQUEZ D.D.S. PLC
Entity Type:Organization
Organization Name:DAVID K. VAZQUEZ D.D.S. PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:K
Authorized Official - Last Name:VAZQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:313-429-1005
Mailing Address - Street 1:1150 MASON ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2801
Mailing Address - Country:US
Mailing Address - Phone:313-429-1005
Mailing Address - Fax:313-429-1008
Practice Address - Street 1:1150 MASON ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2801
Practice Address - Country:US
Practice Address - Phone:313-429-1005
Practice Address - Fax:313-429-1008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-24
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1487905998Medicaid
MI1043749492Medicaid
MI1154701969Medicaid