Provider Demographics
NPI:1043362650
Name:VALLEJO, LONI A (DDS)
Entity Type:Individual
Prefix:
First Name:LONI
Middle Name:A
Last Name:VALLEJO
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 1:12075 E STATE ROUTE 69
Mailing Address - Street 2:STE A
Mailing Address - City:DEWEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86327-4517
Mailing Address - Country:US
Mailing Address - Phone:928-277-0142
Mailing Address - Fax:928-277-0151
Practice Address - Street 1:2179 W 24TH ST
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-6240
Practice Address - Country:US
Practice Address - Phone:928-782-4707
Practice Address - Fax:928-782-2212
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ70781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice