Provider Demographics
NPI:1841596954
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:OWNER
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 1:3127 BALDWIN PARK BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-4754
Mailing Address - Country:US
Mailing Address - Phone:626-962-3500
Mailing Address - Fax:626-962-3551
Practice Address - Street 1:3127 BALDWIN PARK BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-4754
Practice Address - Country:US
Practice Address - Phone:626-962-3500
Practice Address - Fax:626-962-3551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-07
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30715261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental