MEDICARE: BERNARDINO OCTAVIO ELIZONDO D.D.S. P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	19338	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G60092-01	OTHER	TX	TEXAS CHIP
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1851404420
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BERNARDINO OCTAVIO ELIZONDO D.D.S. P.C.

Provider Business Mailing Address
First Line	:	1389 W US HIGHWAY 77
Second Line	:	SUITE E
City	:	SAN BENITO
State	:	TX
Zip	:	78586-4161
Country	:	US
Telephone Number	:	956-399-9929
Fax Number	:	956-399-4855

Provider Business Practice Location Address
First Line	:	1389 W US HIGHWAY 77
Second Line	:	SUITE E
City	:	SAN BENITO
State	:	TX
Zip	:	78586-4161
Country	:	US
Telephone Number	:	956-399-9929
Fax Number	:	956-399-4855

Authorized Official
Title or Position	:	OWNER/ PRESIDENT
Name	:	DR. BERNARDINO OCTAVIO ELIZONDO
Credential	:	D.D.S.
Telephone Number	:	956-399-9929

Provider Enumeration Date	:	08/16/2006
Last Update Date	:	04/23/2010

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