Healthcare Provider Details

I. General information

NPI: 1134270606
Provider Name (Legal Business Name): ILIANA CUELLAR D.D.S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2007
Last Update Date: 02/07/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1063 NORTH D STREET
SAN BERNARDINO CA
92410
US

IV. Provider business mailing address

1063 NORTH D STREET
SAN BERNARDINO CA
92410
US

V. Phone/Fax

Practice location:
  • Phone: 323-582-5411
  • Fax: 323-582-5568
Mailing address:
  • Phone: 909-763-2581
  • Fax: 323-582-5568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number50235
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDDS50235
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: