Healthcare Provider Details

I. General information

NPI: 1720782006
Provider Name (Legal Business Name): JOSEPH VIGODA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2023
Last Update Date: 08/22/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3057 GENTILLY BLVD
NEW ORLEANS LA
70122-3807
US

IV. Provider business mailing address

98 WOOD END LN
MEDFIELD MA
02052-2224
US

V. Phone/Fax

Practice location:
  • Phone: 504-399-7999
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN10000523
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7623
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: