Healthcare Provider Details

I. General information

NPI: 1558417360
Provider Name (Legal Business Name): NONATO H. ELAZEGUI DDS DENTAL CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 12/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12384 AVENUE 416 SUITE AB
OROSI CA
93647-9463
US

IV. Provider business mailing address

12384 AVENUE 416 SUITE AB
OROSI CA
93647-9463
US

V. Phone/Fax

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

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: NONATO ELAZEGUI
Title or Position: PRESIDENT
Credential: DDS
Phone: 558-528-2244