Provider Demographics
NPI:1508165929
Name:ELENES DENTAL CORPORATION
Entity Type:Organization
Organization Name:ELENES DENTAL CORPORATION
Other - Org Name:LEGACY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ELENES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-637-2600
Mailing Address - Street 1:11330 LONG BEACH BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-3340
Mailing Address - Country:US
Mailing Address - Phone:310-637-2600
Mailing Address - Fax:310-637-2638
Practice Address - Street 1:11330 LONG BEACH BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-3340
Practice Address - Country:US
Practice Address - Phone:310-637-2600
Practice Address - Fax:310-637-2638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-24
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30715292200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes292200000XLaboratoriesDental Laboratory