Provider Demographics
NPI:1679775829
Name:BAQUERO, ELVIS (DDS)
Entity type:Individual
Prefix:
First Name:ELVIS
Middle Name:
Last Name:BAQUERO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 N AVALON BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:90744-1506
Mailing Address - Country:US
Mailing Address - Phone:760-232-6471
Mailing Address - Fax:760-496-1154
Practice Address - Street 1:1455 N AVALON BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:CA
Practice Address - Zip Code:90744
Practice Address - Country:US
Practice Address - Phone:310-561-8711
Practice Address - Fax:760-496-1154
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA490591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA82-3721638OtherIRS