Provider Demographics
NPI:1669609574
Name:VARGAS, GUSTAVO ANTONIO (RDA)
Entity type:Individual
Prefix:MR
First Name:GUSTAVO
Middle Name:ANTONIO
Last Name:VARGAS
Suffix:
Gender:M
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11054 PASO ROBLES AVE
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-4934
Mailing Address - Country:US
Mailing Address - Phone:818-470-9203
Mailing Address - Fax:
Practice Address - Street 1:11054 PASO ROBLES AVE
Practice Address - Street 2:
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344
Practice Address - Country:US
Practice Address - Phone:818-470-9203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63428126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant