Provider Demographics
NPI:1497914501
Name:DAVIDSON, ELENA ISABELLA (DDS)
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:ISABELLA
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:443 JOAQUIN AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-4902
Mailing Address - Country:US
Mailing Address - Phone:510-352-9212
Mailing Address - Fax:510-352-4313
Practice Address - Street 1:443 JOAQUIN AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4902
Practice Address - Country:US
Practice Address - Phone:510-352-9212
Practice Address - Fax:510-352-4313
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56975122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist