Healthcare Provider Details

I. General information

NPI: 1811593494
Provider Name (Legal Business Name): YAILI VEGA BORREGO CRDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2020
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12123 LITTLE RD
HUDSON FL
34667-2924
US

IV. Provider business mailing address

12123 LITTLE RD
HUDSON FL
34667-2924
US

V. Phone/Fax

Practice location:
  • Phone: 727-379-9250
  • Fax:
Mailing address:
  • Phone: 727-379-9250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH25183
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: