Provider Demographics
NPI:1306181037
Name:ELVIS BAQUERO DDS, INC.
Entity Type:Organization
Organization Name:ELVIS BAQUERO DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BAQUERO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:760-856-1056
Mailing Address - Street 1:HC 1 BOX 300
Mailing Address - Street 2:
Mailing Address - City:NIPTON
Mailing Address - State:CA
Mailing Address - Zip Code:92364-9735
Mailing Address - Country:US
Mailing Address - Phone:760-856-1056
Mailing Address - Fax:760-856-1050
Practice Address - Street 1:100826 NIPTON RD
Practice Address - Street 2:
Practice Address - City:NIPTON
Practice Address - State:CA
Practice Address - Zip Code:92364
Practice Address - Country:US
Practice Address - Phone:760-856-1056
Practice Address - Fax:760-856-1050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-06
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA490591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty