Healthcare Provider Details

I. General information

NPI: 1679288104
Provider Name (Legal Business Name): ETHAN MICHAEL ELIZONDO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2023
Last Update Date: 01/19/2023
Certification Date: 01/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4915 25TH AVE NE
SEATTLE WA
98105-5667
US

IV. Provider business mailing address

223 CIRCLE DR
CORPUS CHRISTI TX
78411-1232
US

V. Phone/Fax

Practice location:
  • Phone: 206-524-1600
  • Fax: 206-524-1603
Mailing address:
  • Phone: 361-960-3687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: