Healthcare Provider Details

I. General information

NPI: 1306389093
Provider Name (Legal Business Name): ELINEIDA PEREZ D.D.S.M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2016
Last Update Date: 11/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 N 4TH ST STE C
LONGVIEW TX
75601-5439
US

IV. Provider business mailing address

815 N 4TH ST STE C
LONGVIEW TX
75601-5439
US

V. Phone/Fax

Practice location:
  • Phone: 903-757-8890
  • Fax: 903-757-7198
Mailing address:
  • Phone: 903-757-8890
  • Fax: 903-757-7198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number32510
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: