Provider Demographics
NPI:1750164307
Name:TOLENTINO, ELVIN GUADIZ
Entity type:Individual
Prefix:
First Name:ELVIN
Middle Name:GUADIZ
Last Name:TOLENTINO
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 1:2226 WILD CANYON DR
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-9233
Mailing Address - Country:US
Mailing Address - Phone:909-827-0467
Mailing Address - Fax:
Practice Address - Street 1:159 W HOSPITALITY LN
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3348
Practice Address - Country:US
Practice Address - Phone:909-558-4960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-17
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS108982122300000X
NE7970122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist