Provider Demographics
NPI:1952957268
Name:VEGA, RENE GACIVES
Entity Type:Individual
Prefix:
First Name:RENE
Middle Name:GACIVES
Last Name:VEGA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16663 HEMINGWAY DR
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-1181
Mailing Address - Country:US
Mailing Address - Phone:714-659-3630
Mailing Address - Fax:
Practice Address - Street 1:16663 HEMINGWAY DR
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326-1181
Practice Address - Country:US
Practice Address - Phone:714-659-3630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-13
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN245151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice