Provider Demographics
NPI:1407105083
Name:KAN, ELENA (DDS, MS)
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:
Last Name:KAN
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 JACKSON ST N STE 250
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33705-1449
Mailing Address - Country:US
Mailing Address - Phone:727-289-2981
Mailing Address - Fax:727-280-5225
Practice Address - Street 1:560 JACKSON ST N STE 250
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-1449
Practice Address - Country:US
Practice Address - Phone:727-289-2981
Practice Address - Fax:727-280-5225
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-29
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN21445122300000X, 1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist