=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699464438
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VICTOR HUGO VIVEROS DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2023
-----------------------------------------------------
Last Update Date | 07/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 CARLSBAD VILLAGE DR STE 203
-----------------------------------------------------
City | CARLSBAD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92008-2990
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-487-0203
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4805 CORTE OLIVAS
-----------------------------------------------------
City | CAMARILLO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93012-4041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-816-9068
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 110195
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------