Provider Demographics
NPI:1043888936
Name:CORONADO CANYON DENTISTREE
Entity Type:Organization
Organization Name:CORONADO CANYON DENTISTREE
Other - Org Name:ELEAZAR VIRAY SANTIAGO GEN PTR
Other - Org Type:Other Name
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELEAZAR
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTIAGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-610-8734
Mailing Address - Street 1:660 S GREEN VALLEY PKWY STE 110
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-0431
Mailing Address - Country:US
Mailing Address - Phone:702-610-8734
Mailing Address - Fax:
Practice Address - Street 1:660 S GREEN VALLEY PKWY STE 110
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-0431
Practice Address - Country:US
Practice Address - Phone:702-610-8734
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-16
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty