Provider Demographics
NPI:1376019265
Name:FERNANDEZ, ELISE K (DDS)
Entity type:Individual
Prefix:DR
First Name:ELISE
Middle Name:K
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 N LA BREA AVE APT 368
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90038-2363
Mailing Address - Country:US
Mailing Address - Phone:305-972-5122
Mailing Address - Fax:
Practice Address - Street 1:12121 WILSHIRE BLVD STE 1111
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1188
Practice Address - Country:US
Practice Address - Phone:310-409-4265
Practice Address - Fax:310-820-0588
Is Sole Proprietor?:No
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103272122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA103272Medicaid