1023654241 NPI number — ELMER A. VILLALON, DMD, LLC

Table of content: (NPI 1023654241)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023654241 NPI number — ELMER A. VILLALON, DMD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELMER A. VILLALON, DMD, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023654241
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/22/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1225 N MAIN ST STE 207
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUEBLO
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81003-2857
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-542-7844
Provider Business Mailing Address Fax Number:
719-542-7870

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1225 NORTH MAIN STREET
Provider Second Line Business Practice Location Address:
#207
Provider Business Practice Location Address City Name:
PUEBLO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-542-7844
Provider Business Practice Location Address Fax Number:
719-542-7870
Provider Enumeration Date:
11/22/2019

Additional Information

Authorized Official

Authorized Official Last Name:
VILLALON
Authorized Official First Name:
ELMER
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
719-542-7844

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02059525 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com