Healthcare Provider Details

I. General information

NPI: 1912011099
Provider Name (Legal Business Name): JOHN EDWARD ELLIOTT D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 S MAIN ST STE 104
CORONA CA
92882-3401
US

IV. Provider business mailing address

3405 E AUSTIN AVE
ORANGE CA
92869-5231
US

V. Phone/Fax

Practice location:
  • Phone: 951-278-3304
  • Fax:
Mailing address:
  • Phone: 714-299-9267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDE 33281
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: