Provider Demographics
NPI:1205906872
Name:SAN ANTONIO DENTAL OFFICE ELVIA JUAREZ DENTAL CORP
Entity type:Organization
Organization Name:SAN ANTONIO DENTAL OFFICE ELVIA JUAREZ DENTAL CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:ELVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JUAREZ MATA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:760-398-9848
Mailing Address - Street 1:51335 HARRISON ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:COACHELLA
Mailing Address - State:CA
Mailing Address - Zip Code:92236
Mailing Address - Country:US
Mailing Address - Phone:760-398-9848
Mailing Address - Fax:760-398-9877
Practice Address - Street 1:51335 HARRISON ST
Practice Address - Street 2:SUITE 107
Practice Address - City:COACHELLA
Practice Address - State:CA
Practice Address - Zip Code:92236
Practice Address - Country:US
Practice Address - Phone:760-398-9848
Practice Address - Fax:760-398-9877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA416251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB4162503Medicare ID - Type Unspecified