Provider Demographics
NPI:1194275115
Name:ELVIA HERNANDEZ BANUELOS
Entity type:Organization
Organization Name:ELVIA HERNANDEZ BANUELOS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ELVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ BANUELOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:602-774-4309
Mailing Address - Street 1:4275 EXECUTIVE SQ
Mailing Address - Street 2:STE 200
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-9123
Mailing Address - Country:US
Mailing Address - Phone:800-743-3900
Mailing Address - Fax:
Practice Address - Street 1:AVE A BETWWEN 2ND AND 3RD,
Practice Address - Street 2:
Practice Address - City:LOS ALGODONES
Practice Address - State:BAJA CALIFORNIA
Practice Address - Zip Code:21970
Practice Address - Country:MX
Practice Address - Phone:602-774-4309
Practice Address - Fax:866-272-6924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-13
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ2962838122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty