Healthcare Provider Details

I. General information

NPI: 1467226795
Provider Name (Legal Business Name): ELVIA JUAREZ A DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2023
Last Update Date: 11/07/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 W RAMSEY ST
BANNING CA
92220-3503
US

IV. Provider business mailing address

82204 US HIGHWAY 111
INDIO CA
92201-5630
US

V. Phone/Fax

Practice location:
  • Phone: 760-775-5552
  • Fax:
Mailing address:
  • Phone: 760-775-5552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ELVIA JUAREZ-MATA
Title or Position: OWNER
Credential: DDS
Phone: 760-775-5552