Provider Demographics
NPI:1053512913
Name:MALDONADO, ELVA DOLORES (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELVA
Middle Name:DOLORES
Last Name:MALDONADO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:ELVA
Other - Middle Name:D
Other - Last Name:MALDONADO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:151 W COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723
Mailing Address - Country:US
Mailing Address - Phone:626-332-2550
Mailing Address - Fax:626-339-1933
Practice Address - Street 1:151 W COLLEGE ST
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723
Practice Address - Country:US
Practice Address - Phone:626-332-2550
Practice Address - Fax:626-339-1933
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA461071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG89973-01OtherDENTI-CAL
CAG89973-01Medicaid