Provider Demographics
NPI:1437641008
Name:KHALIL, ELVIRA
Entity Type:Individual
Prefix:
First Name:ELVIRA
Middle Name:
Last Name:KHALIL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4424 BONITA RD
Mailing Address - Street 2:
Mailing Address - City:BONITA
Mailing Address - State:CA
Mailing Address - Zip Code:91902-1423
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4424 BONITA RD
Practice Address - Street 2:
Practice Address - City:BONITA
Practice Address - State:CA
Practice Address - Zip Code:91902-1423
Practice Address - Country:US
Practice Address - Phone:619-473-0392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-30
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23720124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
538938891OtherPASSPORT