Healthcare Provider Details

I. General information

NPI: 1497519086
Provider Name (Legal Business Name): ALFREDO BREST VICO, D.D.S, CO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2024
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 W VENTURA ST STE F
FILLMORE CA
93015-1800
US

IV. Provider business mailing address

751 W VENTURA ST STE F
FILLMORE CA
93015-1800
US

V. Phone/Fax

Practice location:
  • Phone: 805-524-5009
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ALFREDO VICO
Title or Position: OWNER
Credential:
Phone: 404-593-3578