Provider Demographics
NPI:1730888215
Name:FONSECA, ELIJAH (DENTAL TECHNICIAN)
Entity type:Individual
Prefix:MR
First Name:ELIJAH
Middle Name:
Last Name:FONSECA
Suffix:
Gender:M
Credentials:DENTAL TECHNICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2521 N TEJON ST REAR ALLEY
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-6836
Mailing Address - Country:US
Mailing Address - Phone:719-308-9009
Mailing Address - Fax:
Practice Address - Street 1:2521 N TEJON ST REAR ALLEY
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-6836
Practice Address - Country:US
Practice Address - Phone:719-308-9009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-23
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COR007828321223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics