Healthcare Provider Details

I. General information

NPI: 1548778541
Provider Name (Legal Business Name): ELIAS & JUN DENTAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2018
Last Update Date: 01/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 S. FAIR OAKS AVE. STE 107
PASADENA CA
91105
US

IV. Provider business mailing address

301 S. FAIR OAKS AVE. STE 107
PASADENA CA
91105
US

V. Phone/Fax

Practice location:
  • Phone: 626-440-0099
  • Fax: 626-440-1002
Mailing address:
  • Phone: 626-440-0099
  • Fax: 626-440-1002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: DR. YOUNG JUN
Title or Position: VICE PRESIDENT
Credential: DDS, M.D.
Phone: 818-282-4021