Jeremy Ryan Vistica, DMD

Primary specialty

Orthodontics and Dentofacial Orthopedics DentistryTaxonomy code 1223X0400X

License

109231 Issued in CA

Practice address

5512 Maryport Dr
Huntington Beach, CA 92649-4821

Phone

(503) 706-5944

NPI assigned

Oct 16, 2007

Last updated

Oct 1, 2024By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1192492800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1727740800000",
    "number": "1639368582",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12100 MONITOR MCKEE RD NE",
            "city": "WOODBURN",
            "state": "OR",
            "postal_code": "970719089",
            "telephone_number": "503-706-5944"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5512 MARYPORT DR",
            "city": "HUNTINGTON BEACH",
            "state": "CA",
            "postal_code": "926494821",
            "telephone_number": "503-706-5944"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "VISTICA",
        "first_name": "JEREMY",
        "middle_name": "RYAN",
        "credential": "DMD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-10-16",
        "last_updated": "2024-10-01",
        "certification_date": "2024-10-01",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "VA",
            "license": "0401417561",
            "primary": false
        },
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "OR",
            "license": "D8993",
            "primary": false
        },
        {
            "code": "1223X0400X",
            "taxonomy_group": "",
            "desc": "Dentist, Orthodontics and Dentofacial Orthopedics",
            "state": "CA",
            "license": "109231",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "500637605",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Orthodontics and Dentofacial Orthopedics Dentistry in Huntington Beach, CA
• Providers in Huntington Beach, CA by specialty
• Orthodontics and Dentofacial Orthopedics Dentistry in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 1, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.