Provider Demographics
NPI:1689448136
Name:FAVELA CARDONA, LUIS ARMANDO
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:ARMANDO
Last Name:FAVELA CARDONA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BOULEVARD DE LAS ROSAS 181
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:DURANGO
Mailing Address - Zip Code:34200
Mailing Address - Country:MX
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 N STATE COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-2909
Practice Address - Country:US
Practice Address - Phone:714-491-8441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-14
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109646122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty