Provider Demographics
NPI:1265418487
Name:ELIZONDO, BERNARDINO OCTAVIO (DDS)
Entity type:Individual
Prefix:
First Name:BERNARDINO
Middle Name:OCTAVIO
Last Name:ELIZONDO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1389 WEST BUSINESS HWY 77
Mailing Address - Street 2:SUITE E
Mailing Address - City:SAN BENITO
Mailing Address - State:TX
Mailing Address - Zip Code:78586
Mailing Address - Country:US
Mailing Address - Phone:956-399-9929
Mailing Address - Fax:956-399-4855
Practice Address - Street 1:1389 WEST BUSINESS HWY 77
Practice Address - Street 2:SUITE E
Practice Address - City:SAN BENITO
Practice Address - State:TX
Practice Address - Zip Code:78586
Practice Address - Country:US
Practice Address - Phone:956-399-9929
Practice Address - Fax:956-399-4855
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19338122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149837001Medicaid
TX149837001Medicaid
TXU83558Medicare UPIN