Healthcare Provider Details

I. General information

NPI: 1598893489
Provider Name (Legal Business Name): DAVID VACA JR. D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3121 H G MOSELEY PKWY
LONGVIEW TX
75605-2942
US

IV. Provider business mailing address

3121 H G MOSELEY PKWY
LONGVIEW TX
75605-2942
US

V. Phone/Fax

Practice location:
  • Phone: 903-663-0861
  • Fax: 903-663-9148
Mailing address:
  • Phone: 903-663-0861
  • Fax: 903-663-9148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number921862
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: