Provider Demographics
NPI:1871926501
Name:ELVIA JUAREZ A DENTAL CORPORATION
Entity type:Organization
Organization Name:ELVIA JUAREZ A DENTAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ELVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JUAREZ-MATA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:951-302-1376
Mailing Address - Street 1:82204 US HIGHWAY 111
Mailing Address - Street 2:SUITE A
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-5630
Mailing Address - Country:US
Mailing Address - Phone:760-775-5552
Mailing Address - Fax:760-841-1982
Practice Address - Street 1:31500 GRAPE ST STE 8
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92532-9702
Practice Address - Country:US
Practice Address - Phone:951-302-1376
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-16
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty