Provider Demographics
NPI:1033128111
Name:VALDEZ, MARIO GUILLERMO (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:GUILLERMO
Last Name:VALDEZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 N GRAND AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-2611
Mailing Address - Country:US
Mailing Address - Phone:714-667-5946
Mailing Address - Fax:714-667-6935
Practice Address - Street 1:1500 N GRAND AVE STE 102
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-2611
Practice Address - Country:US
Practice Address - Phone:714-667-5946
Practice Address - Fax:714-667-6935
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA508381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice