Healthcare Provider Details

I. General information

NPI: 1437142999
Provider Name (Legal Business Name): VINCENT GERARD AUTH DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1ST DENTAL BATTALION BLDG 13128
CAMP PENDLETON CA
92055-5221
US

IV. Provider business mailing address

3621 LAREDO ST .
CARLSBAD CA
92010-2173
US

V. Phone/Fax

Practice location:
  • Phone: 760-763-1128
  • Fax:
Mailing address:
  • Phone: 760-434-0014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDS026376L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: