Bernardino Octavio Elizondo, DDS
Individual provider Active NPI Dentist · San Benito, TX
NPI 1265418487 · NPPES record last updated Apr 28, 2010
Key facts
- NPI
- 1265418487
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Dentist 122300000X
- License
- 19338 (TX)
- Practice address
- 1389 West Business Hwy 77
Suite E
San Benito, TX 78586 - Phone
- (956) 399-9929
- Fax
- (956) 399-4855
- NPI assigned
- Dec 20, 2005
- Sex
- Male
- Sole proprietor
- No
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 19338 | TX | MD | Dentist |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 19338 | TX | Yes |
Addresses
Primary practice location
1389 West Business Hwy 77
Suite E
San Benito, TX 78586
Mailing address
1389 West Business Hwy 77
Suite E
San Benito, TX 78586
Phone (956) 399-9929
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 149837001 | Medicaid | TX |
Other providers in San Benito, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 28, 2010. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.