Healthcare Provider Details

I. General information

NPI: 1003745084
Provider Name (Legal Business Name): LUIS GALLARDO VEGA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2026
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 LAKEWOOD RANCH BLVD
BRADENTON FL
34211-4953
US

IV. Provider business mailing address

1508 LEIGHTON AVE
LAKELAND FL
33803-2519
US

V. Phone/Fax

Practice location:
  • Phone: 941-405-1600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: