Healthcare Provider Details

I. General information

NPI: 1861091720
Provider Name (Legal Business Name): ELLEN IM DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2020
Last Update Date: 05/06/2021
Certification Date: 05/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13422 POMERADO RD STE 201
POWAY CA
92064-3548
US

IV. Provider business mailing address

13422 POMERADO RD STE 201
POWAY CA
92064-3548
US

V. Phone/Fax

Practice location:
  • Phone: 858-679-6660
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. ELLEN IM
Title or Position: OWNER/OPERATOR
Credential: DDS
Phone: 858-679-6660