Provider Demographics
NPI:1902008568
Name:VISTA, MICHAEL LUKE (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LUKE
Last Name:VISTA
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 1:1950 SPYGLASS DR
Mailing Address - Street 2:
Mailing Address - City:SAN BRUNO
Mailing Address - State:CA
Mailing Address - Zip Code:94066-1048
Mailing Address - Country:US
Mailing Address - Phone:650-355-7230
Mailing Address - Fax:
Practice Address - Street 1:4972 MISSION ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94112-3416
Practice Address - Country:US
Practice Address - Phone:415-333-3400
Practice Address - Fax:415-333-3400
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA544441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA54444OtherDENTAL LICENSE NUMBER