Basic Information
| Provider Information | |||||||||
| NPI: | 1548778541 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ELIAS & JUN DENTAL CORP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE PACIFIC COAST CENTER FOR ORAL & FACIAL SURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 S. FAIR OAKS AVE. | ||||||||
| Address2: | STE 107 | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264400099 | ||||||||
| FaxNumber: | 6264401002 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 S. FAIR OAKS AVE. | ||||||||
| Address2: | STE 107 | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264400099 | ||||||||
| FaxNumber: | 6264401002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2018 | ||||||||
| LastUpdateDate: | 01/12/2018 | ||||||||
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| AuthorizedOfficialLastName: | JUN | ||||||||
| AuthorizedOfficialFirstName: | YOUNG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8182824021 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DDS, M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 208200000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery | 2082S0099X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery | Plastic Surgery Within the Head and Neck | 2086S0122X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery | 204E00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery |
No ID Information.