Provider Demographics
NPI:1275664484
Name:ELLOWAY & WONENBERG, D.D.S., A PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:ELLOWAY & WONENBERG, D.D.S., A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KERISA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:ELLOWAY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:707-442-1140
Mailing Address - Street 1:1519 2ND ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-0701
Mailing Address - Country:US
Mailing Address - Phone:707-442-1140
Mailing Address - Fax:707-442-1038
Practice Address - Street 1:1519 2ND ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-0701
Practice Address - Country:US
Practice Address - Phone:707-442-1140
Practice Address - Fax:707-442-1038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA497061223G0001X
CA472541223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Not Answered1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty