Healthcare Provider Details

I. General information

NPI: 1003982638
Provider Name (Legal Business Name): ELVIA JUAREZ A DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 08/17/2021
Certification Date: 08/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30877 DATE PALM DR STE B4
CATHEDRAL CITY CA
92234-2957
US

IV. Provider business mailing address

30877 DATE PALM DR STE B4
CATHEDRAL CITY CA
92234-2957
US

V. Phone/Fax

Practice location:
  • Phone: 760-202-7400
  • Fax: 760-202-7403
Mailing address:
  • Phone: 760-202-7400
  • Fax: 760-202-7403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number41625
License Number StateCA

VIII. Authorized Official

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