Basic Information
| Provider Information | |||||||||
| NPI: | 1134270606 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CUELLAR | ||||||||
| FirstName: | ILIANA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 8330 LONG BEACH BLVD | ||||||||
| Address2: | 107 | ||||||||
| City: | SOUTH GATE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902802073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3235825411 | ||||||||
| FaxNumber: | 3235825568 | ||||||||
| Practice Location | |||||||||
| Address1: | 8330 LONG BEACH BLVD | ||||||||
| Address2: | 107 | ||||||||
| City: | SOUTH GATE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902802073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3235825411 | ||||||||
| FaxNumber: | 3235825568 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 50235 | CA | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | G92919-01 | 05 | CA | MEDICAID |