Provider Demographics
NPI:1063813814
Name:ELLY SWADIPURA DDS
Entity Type:Organization
Organization Name:ELLY SWADIPURA DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:SWADIPURA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:626-962-2778
Mailing Address - Street 1:13105 RAMONA BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:IRWINDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91706-3858
Mailing Address - Country:US
Mailing Address - Phone:626-962-2778
Mailing Address - Fax:626-338-8669
Practice Address - Street 1:13105 RAMONA BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:IRWINDALE
Practice Address - State:CA
Practice Address - Zip Code:91706-3858
Practice Address - Country:US
Practice Address - Phone:626-962-2778
Practice Address - Fax:626-338-8669
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:369 DENTAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-09-11
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD37508261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG90745-01Medicaid