Provider Demographics
NPI:1447080254
Name:VEGA TERAN, MICHELLE KARINA
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:KARINA
Last Name:VEGA TERAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1494
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85366-2367
Mailing Address - Country:US
Mailing Address - Phone:928-287-1537
Mailing Address - Fax:
Practice Address - Street 1:AVENIDA B #390
Practice Address - Street 2:
Practice Address - City:ALGODONES
Practice Address - State:BAJA CALIFORNIA
Practice Address - Zip Code:21970
Practice Address - Country:MX
Practice Address - Phone:658-596-2838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-06
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ10402998122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist