MEDICARE: DR. MARIBEL VICENTE DMD

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	122300000X	Dentist	42707	CA

General Provider Information

NPI Number	:	1801085758
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARIBEL VICENTE DMD

Provider Business Mailing Address
First Line	:	5555 JACKSON DR
Second Line	:	210
City	:	LA MESA
State	:	CA
Zip	:	91942-2452
Country	:	US
Telephone Number	:	619-462-3552
Fax Number	:	619-271-1514

Provider Business Practice Location Address
First Line	:	5555 JACKSON DR
Second Line	:	210
City	:	LA MESA
State	:	CA
Zip	:	91942-2452
Country	:	US
Telephone Number	:	619-462-3552
Fax Number	:	619-271-1514

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

Provider Enumeration Date	:	10/16/2007
Last Update Date	:	10/29/2007

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