Provider Demographics
NPI:1750692794
Name:JUSTICE, ELENA GUENNADIEVNA (DDS)
Entity type:Individual
Prefix:DR
First Name:ELENA
Middle Name:GUENNADIEVNA
Last Name:JUSTICE
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 1:170 CITY BLVD W APT 101
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-2919
Mailing Address - Country:US
Mailing Address - Phone:714-938-1169
Mailing Address - Fax:
Practice Address - Street 1:4447 SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-4847
Practice Address - Country:US
Practice Address - Phone:310-313-0309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-24
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA593101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice