=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073479663
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LUIS VEGA, DDS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2025
-----------------------------------------------------
Last Update Date | 12/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6520 226TH PL SE STE 205
-----------------------------------------------------
City | ISSAQUAH
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98027-8969
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-477-7723
-----------------------------------------------------
Fax | 425-477-7784
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6520 226TH PL SE STE 205
-----------------------------------------------------
City | ISSAQUAH
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98027-8969
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-477-7723
-----------------------------------------------------
Fax | 425-477-7784
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING MANAGER
-----------------------------------------------------
Name | JENNIFER HERITAGE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 402-805-4516
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------