Provider Demographics
NPI:1609566637
Name:VEGA, JORGE LUIS
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:LUIS
Last Name:VEGA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 ALLEN PKWY STE E200
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77019-1811
Mailing Address - Country:US
Mailing Address - Phone:281-607-5348
Mailing Address - Fax:
Practice Address - Street 1:3201 ALLEN PKWY STE E200
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77019-1811
Practice Address - Country:US
Practice Address - Phone:281-607-5348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-12
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24374124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist