Provider Demographics
NPI:1295512721
Name:COP, ELYSE MICHELLE (RDHAP)
Entity type:Individual
Prefix:MS
First Name:ELYSE
Middle Name:MICHELLE
Last Name:COP
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:MS
Other - First Name:ELYSE
Other - Middle Name:MICHELLE
Other - Last Name:KLOSTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:92 ESENCIA DR UNIT 835
Mailing Address - Street 2:
Mailing Address - City:RANCHO MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92694-1363
Mailing Address - Country:US
Mailing Address - Phone:949-933-0490
Mailing Address - Fax:
Practice Address - Street 1:92 ESENCIA DR UNIT 835
Practice Address - Street 2:
Practice Address - City:RANCHO MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92694-1363
Practice Address - Country:US
Practice Address - Phone:949-933-0490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-08
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27213124Q00000X
CA1016125K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125K00000XDental ProvidersAdvanced Practice Dental Therapist
No124Q00000XDental ProvidersDental Hygienist