Provider Demographics
NPI:1851404420
Name:BERNARDINO OCTAVIO ELIZONDO D.D.S. P.C.
Entity Type:Organization
Organization Name:BERNARDINO OCTAVIO ELIZONDO D.D.S. P.C.
Other - Org Name:SUNSHINE FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BERNARDINO
Authorized Official - Middle Name:OCTAVIO
Authorized Official - Last Name:ELIZONDO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:956-399-9929
Mailing Address - Street 1:1389 W US HIGHWAY 77
Mailing Address - Street 2:SUITE E
Mailing Address - City:SAN BENITO
Mailing Address - State:TX
Mailing Address - Zip Code:78586-4161
Mailing Address - Country:US
Mailing Address - Phone:956-399-9929
Mailing Address - Fax:956-399-4855
Practice Address - Street 1:1389 W US HIGHWAY 77
Practice Address - Street 2:SUITE E
Practice Address - City:SAN BENITO
Practice Address - State:TX
Practice Address - Zip Code:78586-4161
Practice Address - Country:US
Practice Address - Phone:956-399-9929
Practice Address - Fax:956-399-4855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19338122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG60092-01OtherTEXAS CHIP
TX155609401Medicaid