Provider Demographics
NPI:1548618648
Name:VAJDA, DEREK L (DDS, MD)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:L
Last Name:VAJDA
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1541 CENTINELA AVE APT 105
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-3222
Mailing Address - Country:US
Mailing Address - Phone:219-789-8308
Mailing Address - Fax:
Practice Address - Street 1:1541 CENTINELA AVE APT 105
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-3222
Practice Address - Country:US
Practice Address - Phone:219-789-8308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-31
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD54501223S0112X
CA653631223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery