Healthcare Provider Details

I. General information

NPI: 1194425728
Provider Name (Legal Business Name): ELLIOTT GREGORY PEREIRA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2023
Last Update Date: 03/02/2023
Certification Date: 03/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1807 BAY RD
EAST PALO ALTO CA
94303-1312
US

IV. Provider business mailing address

514 PORPOISE BAY TER APT E
SUNNYVALE CA
94089-4728
US

V. Phone/Fax

Practice location:
  • Phone: 650-289-7700
  • Fax:
Mailing address:
  • Phone: 408-505-5475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number108425
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: