Provider Demographics
NPI:1063635241
Name:FLORES, ENRIQUE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ENRIQUE
Middle Name:
Last Name:FLORES
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 1:721 HAY ST
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-2336
Mailing Address - Country:US
Mailing Address - Phone:323-273-4773
Mailing Address - Fax:
Practice Address - Street 1:15431 AMAR RD
Practice Address - Street 2:
Practice Address - City:LA PUENTE
Practice Address - State:CA
Practice Address - Zip Code:91744-2803
Practice Address - Country:US
Practice Address - Phone:626-968-5110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA473681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD47368OtherMEDI-CAL RENDERING PROVID