Provider Demographics
NPI:1033232590
Name:VILLALON, ELMER ALEX (DMD)
Entity Type:Individual
Prefix:DR
First Name:ELMER
Middle Name:ALEX
Last Name:VILLALON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 N MAIN ST
Mailing Address - Street 2:207
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2857
Mailing Address - Country:US
Mailing Address - Phone:719-542-7844
Mailing Address - Fax:719-542-7870
Practice Address - Street 1:1225 N MAIN ST
Practice Address - Street 2:207
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2857
Practice Address - Country:US
Practice Address - Phone:719-542-7844
Practice Address - Fax:719-542-7870
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1059521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02059525Medicaid