=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558417360
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NONATO H. ELAZEGUI DDS DENTAL CORP.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2007
-----------------------------------------------------
Last Update Date | 12/16/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12384 AVENUE 416 SUITE AB
-----------------------------------------------------
City | OROSI
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93647-9463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-528-2244
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12384 AVENUE 416 SUITE AB
-----------------------------------------------------
City | OROSI
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93647-9463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-528-2244
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | NONATO ELAZEGUI
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 558-528-2244
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 39956
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------