Provider Demographics
NPI:1770167116
Name:VEGA, MICHELLE JUANITA
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:JUANITA
Last Name:VEGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1ST DNBN ATTN: CREDENTIALS
Mailing Address - Street 2:BOX 555221
Mailing Address - City:CAMP PENDLETON
Mailing Address - State:CA
Mailing Address - Zip Code:92055-5221
Mailing Address - Country:US
Mailing Address - Phone:760-539-2081
Mailing Address - Fax:
Practice Address - Street 1:22 AREA DENTAL CLINIC (CHAPPO) BUILDING 22190 10TH ST
Practice Address - Street 2:
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055-5221
Practice Address - Country:US
Practice Address - Phone:760-725-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19900124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist