Healthcare Provider Details

I. General information

NPI: 1720919566
Provider Name (Legal Business Name): ELKEDWANI DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11695 SLATE AVE STE 100
RIVERSIDE CA
92505-5195
US

IV. Provider business mailing address

11695 SLATE AVE STE 100
RIVERSIDE CA
92505-5195
US

V. Phone/Fax

Practice location:
  • Phone: 661-264-8638
  • Fax:
Mailing address:
  • Phone: 661-264-8638
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MARK ELKEDWANI
Title or Position: CHIEF CLINICAL OFFICER
Credential:
Phone: 661-264-8638