Healthcare Provider Details

I. General information

NPI: 1447884861
Provider Name (Legal Business Name): ADAM TAKEO ELLENTHAL DDS, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2020
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10717 CAMINO RUIZ STE 103
SAN DIEGO CA
92126-2310
US

IV. Provider business mailing address

13308 ENTREKEN AVE
SAN DIEGO CA
92129-2354
US

V. Phone/Fax

Practice location:
  • Phone: 858-536-1111
  • Fax:
Mailing address:
  • Phone: 954-850-2669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number111647
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: