Provider Demographics
NPI:1831312990
Name:VEGA, FREDRICK M
Entity Type:Individual
Prefix:DR
First Name:FREDRICK
Middle Name:M
Last Name:VEGA
Suffix:
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 1:311 W. RIVER ROAD
Mailing Address - Street 2:SUITE #2
Mailing Address - City:HOOKSETT
Mailing Address - State:NH
Mailing Address - Zip Code:03106
Mailing Address - Country:US
Mailing Address - Phone:603-485-7600
Mailing Address - Fax:603-485-8961
Practice Address - Street 1:311 W. RIVER ROAD
Practice Address - Street 2:SUITE #2
Practice Address - City:HOOKSETT
Practice Address - State:NH
Practice Address - Zip Code:03106
Practice Address - Country:US
Practice Address - Phone:603-485-7600
Practice Address - Fax:603-485-8961
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2015-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH18571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH89192070Medicaid