Provider Demographics
NPI:1134270606
Name:CUELLAR, ILIANA (DDS)
Entity type:Individual
Prefix:
First Name:ILIANA
Middle Name:
Last Name:CUELLAR
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 1:1063 NORTH D STREET
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410
Mailing Address - Country:US
Mailing Address - Phone:909-763-2581
Mailing Address - Fax:323-582-5568
Practice Address - Street 1:1063 NORTH D STREET
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410
Practice Address - Country:US
Practice Address - Phone:323-582-5411
Practice Address - Fax:323-582-5568
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-13
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50235122300000X
CADDS502351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG92919-01Medicaid