Healthcare Provider Details

I. General information

NPI: 1871926501
Provider Name (Legal Business Name): ELVIA JUAREZ A DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2013
Last Update Date: 08/17/2021
Certification Date: 08/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31500 GRAPE ST STE 8
LAKE ELSINORE CA
92532-9702
US

IV. Provider business mailing address

82204 US HIGHWAY 111 SUITE A
INDIO CA
92201-5630
US

V. Phone/Fax

Practice location:
  • Phone: 951-302-1376
  • Fax:
Mailing address:
  • Phone: 760-775-5552
  • Fax: 760-841-1982

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: PRESIDENT
Credential: D.D.S
Phone: 951-302-1376