Provider Demographics
NPI:1154628931
Name:IGAL ELYASSI, D.D.S., INC.
Entity Type:Organization
Organization Name:IGAL ELYASSI, D.D.S., INC.
Other - Org Name:WILSHIRE SMILE STUDIO DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IGAL
Authorized Official - Middle Name:
Authorized Official - Last Name:ELYASSI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-937-5773
Mailing Address - Street 1:6200 WILSHIRE BLVD
Mailing Address - Street 2:1609
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5801
Mailing Address - Country:US
Mailing Address - Phone:323-937-5773
Mailing Address - Fax:323-937-9502
Practice Address - Street 1:6200 WILSHIRE BLVD
Practice Address - Street 2:1609
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5801
Practice Address - Country:US
Practice Address - Phone:323-937-5773
Practice Address - Fax:323-937-9502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-14
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA544241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty