Provider Demographics
NPI:1750716452
Name:MAITE VARGAS DENTAL CORPORATION
Entity type:Organization
Organization Name:MAITE VARGAS DENTAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MAITE
Authorized Official - Middle Name:
Authorized Official - Last Name:VARGAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:786-554-9845
Mailing Address - Street 1:500 S BROADWAY
Mailing Address - Street 2:SUITE 246
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-5148
Mailing Address - Country:US
Mailing Address - Phone:855-369-8585
Mailing Address - Fax:
Practice Address - Street 1:500 S BROADWAY
Practice Address - Street 2:SUITE 246
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-5148
Practice Address - Country:US
Practice Address - Phone:855-369-8585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-12
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54219261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA54219OtherDENTAL BOARD OF CALIFORNIA