Healthcare Provider Details

I. General information

NPI: 1457748212
Provider Name (Legal Business Name): PETER MARK VRONTIKIS DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2015
Last Update Date: 05/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7777 WESTSIDE DR APT 469
SAN DIEGO CA
92108-1242
US

IV. Provider business mailing address

7777 WESTSIDE DR APT 469
SAN DIEGO CA
92108-1242
US

V. Phone/Fax

Practice location:
  • Phone: 801-232-7580
  • Fax:
Mailing address:
  • Phone: 801-232-7580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number64437
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number9783596-9921
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: