Healthcare Provider Details

I. General information

NPI: 1568385946
Provider Name (Legal Business Name): ANSELMO LUCIANO ACOSTA VELOZ DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2026 N IMPERIAL AVE STE B
EL CENTRO CA
92243-1607
US

IV. Provider business mailing address

2026 N IMPERIAL AVE STE B
EL CENTRO CA
92243-1607
US

V. Phone/Fax

Practice location:
  • Phone: 760-339-9992
  • Fax: 760-353-3635
Mailing address:
  • Phone: 760-339-9992
  • Fax: 760-353-3635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number113642
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: