Provider Demographics
NPI:1710254784
Name:VALLADARES LAZO, ELISEO ERNESTO (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELISEO
Middle Name:ERNESTO
Last Name:VALLADARES LAZO
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 1:17240 DOWNEY AVE
Mailing Address - Street 2:
Mailing Address - City:BELLFLOWER
Mailing Address - State:CA
Mailing Address - Zip Code:90706-6105
Mailing Address - Country:US
Mailing Address - Phone:562-531-0221
Mailing Address - Fax:
Practice Address - Street 1:17240 DOWNEY AVE.
Practice Address - Street 2:
Practice Address - City:BELLFLOWER
Practice Address - State:CA
Practice Address - Zip Code:90706
Practice Address - Country:US
Practice Address - Phone:502-531-1262
Practice Address - Fax:562-531-0221
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-18
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA610661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice