Provider Demographics
NPI:1750421780
Name:ROSA VEGA, REYNALDO (DMD)
Entity type:Individual
Prefix:
First Name:REYNALDO
Middle Name:
Last Name:ROSA VEGA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1503 AVE ASHFORD
Mailing Address - Street 2:COND LAS OLAS APTO 9A
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00911-1134
Mailing Address - Country:US
Mailing Address - Phone:787-712-8857
Mailing Address - Fax:787-712-8857
Practice Address - Street 1:CARRETERA 181 KM 23
Practice Address - Street 2:BARRIO CELADA
Practice Address - City:GURABO
Practice Address - State:PR
Practice Address - Zip Code:00778
Practice Address - Country:US
Practice Address - Phone:787-712-8857
Practice Address - Fax:787-712-8670
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR23271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR3231180000Medicare UPIN