Provider Demographics
NPI:1790346658
Name:REYNOSO VALDEZ, ELIZABETH (DDS)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:REYNOSO VALDEZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2042 7TH ST
Mailing Address - Street 2:
Mailing Address - City:HUGHSON
Mailing Address - State:CA
Mailing Address - Zip Code:95326-9623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3100 E SERVICE RD STE 101
Practice Address - Street 2:
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307-6422
Practice Address - Country:US
Practice Address - Phone:209-542-9921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-21
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1037001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice