Healthcare Provider Details

I. General information

NPI: 1265578686
Provider Name (Legal Business Name): NICHOLAS CHARLES VEGA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 HOLMES ST
KANSAS CITY MO
64108-2640
US

IV. Provider business mailing address

1939 NW 82ND ST
KANSAS CITY MO
64151-8231
US

V. Phone/Fax

Practice location:
  • Phone: 816-404-0500
  • Fax:
Mailing address:
  • Phone: 913-526-1642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2003013074
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: