=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114297785
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VASQUEZ DENTAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2012
-----------------------------------------------------
Last Update Date | 12/21/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2420 VISTA WAY STE 210
-----------------------------------------------------
City | OCEANSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-724-1102
-----------------------------------------------------
Fax | 760-724-1471
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2420 VISTA WAY STE 210
-----------------------------------------------------
City | OCEANSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92054-6190
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-724-1102
-----------------------------------------------------
Fax | 760-724-1471
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/PEDIATRIC DENTIST
-----------------------------------------------------
Name | DR. JOSE ANGELO RAGON VASQUEZ
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 760-724-1102
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 54036
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------