Provider Demographics
NPI:1215599394
Name:M ELDER DENTAL GROUP CORPORATION
Entity Type:Organization
Organization Name:M ELDER DENTAL GROUP CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CENTRALIZED BILLING
Authorized Official - Prefix:
Authorized Official - First Name:EMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-246-6305
Mailing Address - Street 1:446 MERLOT LN
Mailing Address - Street 2:
Mailing Address - City:AMERICAN CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:94503-1243
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:704 BLOSSOM HILL RD STE 102
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95123-5403
Practice Address - Country:US
Practice Address - Phone:408-225-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-28
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty