Provider Demographics
NPI:1730544990
Name:VALENCIA CHAVEZ, GRELDA ITZELA (DDS)
Entity type:Individual
Prefix:MRS
First Name:GRELDA
Middle Name:ITZELA
Last Name:VALENCIA CHAVEZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4364 BONITA RD #233
Mailing Address - Street 2:
Mailing Address - City:BONITA
Mailing Address - State:CA
Mailing Address - Zip Code:91902-1421
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CALLE ANTONIO CASO #2055-603, ZONA RIO
Practice Address - Street 2:TIJUANA
Practice Address - City:MEXICO
Practice Address - State:BAJA CALIFORNIA
Practice Address - Zip Code:22010
Practice Address - Country:MX
Practice Address - Phone:01152664-972-9420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-15
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ1859111122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist