Provider Demographics
NPI:1114063674
Name:ELAINE GRACE G ELLORIN DMD INC
Entity Type:Organization
Organization Name:ELAINE GRACE G ELLORIN DMD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ELAINE GRACE
Authorized Official - Middle Name:GACUSAN
Authorized Official - Last Name:ELLORIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:408-736-7299
Mailing Address - Street 1:911B E DUANE AVE
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94085-3438
Mailing Address - Country:US
Mailing Address - Phone:408-736-7299
Mailing Address - Fax:408-736-7298
Practice Address - Street 1:911B EAST DUANE AVE
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94085-3438
Practice Address - Country:US
Practice Address - Phone:408-736-7299
Practice Address - Fax:408-736-7298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46788122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty