Provider Demographics
NPI:1881684884
Name:VINES, EDWARD LEROY (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:LEROY
Last Name:VINES
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7880 WREN AVE
Mailing Address - Street 2:SUITE B-121
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-4943
Mailing Address - Country:US
Mailing Address - Phone:408-842-3436
Mailing Address - Fax:408-847-1907
Practice Address - Street 1:7880 WREN AVE
Practice Address - Street 2:SUITE B-121
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-4943
Practice Address - Country:US
Practice Address - Phone:408-842-3436
Practice Address - Fax:408-847-1907
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA265561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice