Provider Demographics
NPI:1457929754
Name:ELBORNO, LANA (DMD)
Entity Type:Individual
Prefix:
First Name:LANA
Middle Name:
Last Name:ELBORNO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 S MAYDE CREEK DR APT 359
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77079-6157
Mailing Address - Country:US
Mailing Address - Phone:630-400-0104
Mailing Address - Fax:
Practice Address - Street 1:12168 BELLAIRE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77072-2642
Practice Address - Country:US
Practice Address - Phone:630-400-0104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-14
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX381311223G0001X
IL019.0331971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty