Provider Demographics
NPI:1942728241
Name:ELLEFSON & MARELICH DENTAL CORPORATION
Entity Type:Organization
Organization Name:ELLEFSON & MARELICH DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:ELLEFSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:707-527-0363
Mailing Address - Street 1:1100 SONOMA AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405
Mailing Address - Country:US
Mailing Address - Phone:707-527-0363
Mailing Address - Fax:707-527-6735
Practice Address - Street 1:1100 SONOMA AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405
Practice Address - Country:US
Practice Address - Phone:707-527-0363
Practice Address - Fax:707-527-6735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-07
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS100710122300000X
1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty