Healthcare Provider Details

I. General information

NPI: 1205989589
Provider Name (Legal Business Name): NONATO H ELAZEGUI DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 05/05/2021
Certification Date: 05/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12384 AVENUE 416 STE AB
OROSI CA
93647-9463
US

IV. Provider business mailing address

12384 AVENUE 416 STE AB
OROSI CA
93647-9463
US

V. Phone/Fax

Practice location:
  • Phone: 559-528-2244
  • Fax: 559-528-4460
Mailing address:
  • Phone: 559-528-2244
  • Fax: 559-528-4460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number39956
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: