Provider Demographics
NPI:1427398882
Name:ELLEFSON, LAURA DAVID (DMD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:DAVID
Last Name:ELLEFSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 SONOMA AVE STE A
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-8901
Mailing Address - Country:US
Mailing Address - Phone:707-527-0363
Mailing Address - Fax:
Practice Address - Street 1:1100 SONOMA AVE STE A
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-8901
Practice Address - Country:US
Practice Address - Phone:707-527-0363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-22
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100710122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO70339520Medicaid