Provider Demographics
NPI:1295914158
Name:JOHN T. ELI, D.M.D., M.S.D., INC.
Entity type:Organization
Organization Name:JOHN T. ELI, D.M.D., M.S.D., INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:ELI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MSD
Authorized Official - Phone:949-855-8480
Mailing Address - Street 1:21791 LAKE FOREST DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-2760
Mailing Address - Country:US
Mailing Address - Phone:949-855-8480
Mailing Address - Fax:
Practice Address - Street 1:21791 LAKE FOREST DR
Practice Address - Street 2:SUITE 204
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-2760
Practice Address - Country:US
Practice Address - Phone:949-855-8480
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA523811223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty