Healthcare Provider Details

I. General information

NPI: 1578942942
Provider Name (Legal Business Name): EMILY VACCAREZZA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2015
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2446 FENTON ST STE 102
CHULA VISTA CA
91914-3516
US

IV. Provider business mailing address

2774 WORDEN ST
SAN DIEGO CA
92110-5704
US

V. Phone/Fax

Practice location:
  • Phone: 619-216-1100
  • Fax: 619-216-1127
Mailing address:
  • Phone: 209-815-5244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number101468
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: