Provider Demographics
NPI:1396825949
Name:ELIZONDO, EUTIQUIO M JR (DDS)
Entity type:Individual
Prefix:DR
First Name:EUTIQUIO
Middle Name:M
Last Name:ELIZONDO
Suffix:JR
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 1:100 E EBONY LANE
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78539
Mailing Address - Country:US
Mailing Address - Phone:956-380-3636
Mailing Address - Fax:956-316-3866
Practice Address - Street 1:100 E EBONY LANE
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539
Practice Address - Country:US
Practice Address - Phone:956-380-3636
Practice Address - Fax:956-316-3866
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX742912615122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111245001Medicaid
B14495OtherTEXAS CHIP