Healthcare Provider Details

I. General information

NPI: 1366361701
Provider Name (Legal Business Name): ANDRES VACA DIEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11151 SOUTHERN BLVD STE 110
ROYAL PALM BEACH FL
33411-4260
US

IV. Provider business mailing address

168 PORGEE ROCK PL
JUPITER FL
33458-1634
US

V. Phone/Fax

Practice location:
  • Phone: 561-383-1975
  • Fax:
Mailing address:
  • Phone: 561-383-1975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN31709
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: