Provider Demographics
NPI:1801085758
Name:VICENTE, MARIBEL (DMD)
Entity type:Individual
Prefix:DR
First Name:MARIBEL
Middle Name:
Last Name:VICENTE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5555 JACKSON DR
Mailing Address - Street 2:210
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-2452
Mailing Address - Country:US
Mailing Address - Phone:619-462-3552
Mailing Address - Fax:619-271-1514
Practice Address - Street 1:5555 JACKSON DR
Practice Address - Street 2:210
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-2452
Practice Address - Country:US
Practice Address - Phone:619-462-3552
Practice Address - Fax:619-271-1514
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-16
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42707122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist