Provider Demographics
NPI:1982057766
Name:VOLVOVIC, ELIJAH
Entity Type:Individual
Prefix:
First Name:ELIJAH
Middle Name:
Last Name:VOLVOVIC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 COMMERCIAL ST SE
Mailing Address - Street 2:514
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3421
Mailing Address - Country:US
Mailing Address - Phone:503-363-2536
Mailing Address - Fax:
Practice Address - Street 1:1595 COMMERCIAL ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4309
Practice Address - Country:US
Practice Address - Phone:503-363-2536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-18
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD10489122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist