Provider Demographics
NPI:1912319542
Name:BRENES VEGA, CHRISTIAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHRISTIAN
Middle Name:
Last Name:BRENES VEGA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:CHRISTIAN
Other - Middle Name:
Other - Last Name:BRENES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1430 JOHN WESLEY GILBERT DR
Mailing Address - Street 2:GC-3224
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-0001
Mailing Address - Country:US
Mailing Address - Phone:706-721-8235
Mailing Address - Fax:706-723-0214
Practice Address - Street 1:1430 JOHN WESLEY GILBERT DR
Practice Address - Street 2:GC-3224
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0001
Practice Address - Country:US
Practice Address - Phone:706-721-8235
Practice Address - Fax:706-723-0214
Is Sole Proprietor?:No
Enumeration Date:2014-06-02
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC150861390200000X
TX30425122300000X
GADNF000394122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program