Provider Demographics
NPI:1649995655
Name:ELIE, OMID JONATHAN (DDS)
Entity type:Individual
Prefix:DR
First Name:OMID
Middle Name:JONATHAN
Last Name:ELIE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 FLYING MIST ISLE
Mailing Address - Street 2:
Mailing Address - City:FOSTER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94404-1402
Mailing Address - Country:US
Mailing Address - Phone:650-573-5670
Mailing Address - Fax:
Practice Address - Street 1:925 N SAN ANTONIO RD
Practice Address - Street 2:
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94022-1308
Practice Address - Country:US
Practice Address - Phone:650-559-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA108202122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist