Healthcare Provider Details

I. General information

NPI: 1205906872
Provider Name (Legal Business Name): SAN ANTONIO DENTAL OFFICE ELVIA JUAREZ DENTAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51335 HARRISON ST SUITE 107
COACHELLA CA
92236
US

IV. Provider business mailing address

51335 HARRISON ST SUITE 107
COACHELLA CA
92236
US

V. Phone/Fax

Practice location:
  • Phone: 760-398-9848
  • Fax: 760-398-9877
Mailing address:
  • Phone: 760-398-9848
  • Fax: 760-398-9877

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: DENTIST
Credential: DDS
Phone: 760-398-9848