Healthcare Provider Details

I. General information

NPI: 1760633341
Provider Name (Legal Business Name): M ELDER D D S A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2008
Last Update Date: 08/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 APPIAN WAY STE 201 PINOLE ORAL SURGERY
PINOLE CA
94564-2520
US

IV. Provider business mailing address

140 ADMIRAL CALLAGHAN LANE STE B
VALLEJO CA
94591
US

V. Phone/Fax

Practice location:
  • Phone: 510-724-3922
  • Fax: 510-724-1037
Mailing address:
  • Phone: 415-892-1190
  • Fax: 415-892-7355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number46586
License Number StateCA

VIII. Authorized Official

Name: DR. MAHR FAIRUKE ELDER
Title or Position: PRESIDENT / CEO
Credential: DDS, MD
Phone: 415-892-1190