MEDICARE: LEROY VEGO DDS MS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	15606	CA

General Provider Information

NPI Number	:	1316042062
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEROY VEGO DDS MS

Provider Business Mailing Address
First Line	:	1319 LACHMAN LANE
Second Line	:
City	:	PACIFIC PALISADES
State	:	CA
Zip	:	90272
Country	:	US
Telephone Number	:	310-230-9636
Fax Number	:	310-230-9916

Provider Business Practice Location Address
First Line	:	UCLA SCHOOL OF DENTISTRY
Second Line	:	10833 LECONTE AVE 20-140
City	:	LOS ANGELES
State	:	CA
Zip	:	90095-1668
Country	:	US
Telephone Number	:	310-206-1770
Fax Number	:	310-206-5349

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2006
Last Update Date	:	07/08/2007

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