Basic Information
| Provider Information | |||||||||
| NPI: | 1093157042 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ELIE PROFESSIONAL DENTAL CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | VALENCIA DENTAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2860 MICHELLE FL 2 | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926061008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148458890 | ||||||||
| FaxNumber: | 9494741495 | ||||||||
| Practice Location | |||||||||
| Address1: | 26938 THE OLD RD | ||||||||
| Address2: | |||||||||
| City: | VALENCIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913810662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6617990886 | ||||||||
| FaxNumber: | 6617992655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2013 | ||||||||
| LastUpdateDate: | 07/18/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ELIE | ||||||||
| AuthorizedOfficialFirstName: | ARASH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 6617990886 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.