Provider Demographics
NPI:1942702857
Name:AVALOS, IRVING
Entity Type:Individual
Prefix:
First Name:IRVING
Middle Name:
Last Name:AVALOS
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 1:2085 PORTER ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407-6540
Mailing Address - Country:US
Mailing Address - Phone:909-600-4870
Mailing Address - Fax:
Practice Address - Street 1:1160 E ONTARIO AVE
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92881-8653
Practice Address - Country:US
Practice Address - Phone:951-531-9504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-06
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDA86861126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant