MEDICARE: LINA VEGA D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	055011-1	NY

General Provider Information

NPI Number	:	1114169158
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LINA VEGA D.D.S.

Provider Business Mailing Address
First Line	:	4292 LAKE AVE
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14612-4808
Country	:	US
Telephone Number	:	585-663-3957
Fax Number	:

Provider Business Practice Location Address
First Line	:	625 ELMWOOD AVE
Second Line	:	EASTMAN DENTAL CENTER
City	:	ROCHESTER
State	:	NY
Zip	:	14620
Country	:	US
Telephone Number	:	585-275-5051
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/06/2009
Last Update Date	:	02/13/2023

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