Provider Demographics
NPI:1194187088
Name:ELVIA RODRIGUEZ OLMEDO
Entity type:Organization
Organization Name:ELVIA RODRIGUEZ OLMEDO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ OLMEDO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:01152664-685-5174
Mailing Address - Street 1:4364 BONITA RD #233
Mailing Address - Street 2:
Mailing Address - City:BONITA
Mailing Address - State:CA
Mailing Address - Zip Code:91902-1421
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CALLE 3A CARRILLO PUERTO #8238
Practice Address - Street 2:ZONA CENTRO
Practice Address - City:TIJUANA
Practice Address - State:BAJA CALIFORNIA
Practice Address - Zip Code:22000
Practice Address - Country:MX
Practice Address - Phone:01152664-685-5174
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ1640830122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty