Healthcare Provider Details

I. General information

NPI: 1710774575
Provider Name (Legal Business Name): DAVID VACA JR DDS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2025
Last Update Date: 04/23/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3121 H G MOSLEY PKWY
LONGVIEW TX
75605-2942
US

IV. Provider business mailing address

3121 H G MOSLEY PKWY
LONGVIEW TX
75605-2942
US

V. Phone/Fax

Practice location:
  • Phone: 903-663-5895
  • Fax: 903-663-9148
Mailing address:
  • Phone: 903-663-5895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID VACA JR.
Title or Position: OWNER
Credential: DDS
Phone: 903-663-5895