Healthcare Provider Details

I. General information

NPI: 1245239532
Provider Name (Legal Business Name): DR. VANESSA LYNETTE VAZQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: VANESSA LYNETTE VAZQUEZ D.M.D

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 CALLE MUNOZ RIVERA
TOA BAJA PR
00949-2443
US

IV. Provider business mailing address

1708 CALLE SAN GUILLERMO
SAN JUAN PR
00927-6550
US

V. Phone/Fax

Practice location:
  • Phone: 787-794-9085
  • Fax: 787-794-9085
Mailing address:
  • Phone: 787-758-3309
  • Fax: 787-794-9085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1695
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: