Provider Demographics
NPI:1285004937
Name:GRIN, ELENA (DA)
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:
Last Name:GRIN
Suffix:
Gender:F
Credentials:DA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4305 TORRANCE BLVD STE 505
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-4496
Mailing Address - Country:US
Mailing Address - Phone:310-933-6650
Mailing Address - Fax:855-808-4551
Practice Address - Street 1:4305 TORRANCE BLVD STE 505
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4496
Practice Address - Country:US
Practice Address - Phone:310-933-6650
Practice Address - Fax:855-808-4551
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33289126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant