Provider Demographics
NPI:1003982638
Name:ELVIA JUAREZ A DENTAL CORPORATION
Entity type:Organization
Organization Name:ELVIA JUAREZ A DENTAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ DDS
Authorized Official - Prefix:
Authorized Official - First Name:ELVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JUAREZ MATA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-775-5552
Mailing Address - Street 1:30877 DATE PALM DR STE B4
Mailing Address - Street 2:
Mailing Address - City:CATHEDRAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92234-2957
Mailing Address - Country:US
Mailing Address - Phone:760-202-7400
Mailing Address - Fax:760-202-7403
Practice Address - Street 1:30877 DATE PALM DR STE B4
Practice Address - Street 2:
Practice Address - City:CATHEDRAL CITY
Practice Address - State:CA
Practice Address - Zip Code:92234-2957
Practice Address - Country:US
Practice Address - Phone:760-202-7400
Practice Address - Fax:760-202-7403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA416251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty