Provider Demographics
NPI:1134381049
Name:SUAYAN, JOSE ELIZALDE
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:ELIZALDE
Last Name:SUAYAN
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 1:1800 E GRAND AVE STE G
Mailing Address - Street 2:
Mailing Address - City:GROVER BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93433-5220
Mailing Address - Country:US
Mailing Address - Phone:805-489-1810
Mailing Address - Fax:805-489-1850
Practice Address - Street 1:1800 E GRAND AVE STE G
Practice Address - Street 2:
Practice Address - City:GROVER BEACH
Practice Address - State:CA
Practice Address - Zip Code:93433-5220
Practice Address - Country:US
Practice Address - Phone:805-489-1810
Practice Address - Fax:805-489-1850
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-01
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA437351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice