Provider Demographics
NPI:1760633341
Name:M ELDER D D S A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:M ELDER D D S A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MAHR
Authorized Official - Middle Name:FAIRUKE
Authorized Official - Last Name:ELDER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:415-892-1190
Mailing Address - Street 1:140 ADMIRAL CALLAGHAN LANE STE B
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94591
Mailing Address - Country:US
Mailing Address - Phone:415-892-1190
Mailing Address - Fax:415-892-7355
Practice Address - Street 1:2150 APPIAN WAY STE 201
Practice Address - Street 2:PINOLE ORAL SURGERY
Practice Address - City:PINOLE
Practice Address - State:CA
Practice Address - Zip Code:94564-2520
Practice Address - Country:US
Practice Address - Phone:510-724-3922
Practice Address - Fax:510-724-1037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-01
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA465861223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty