Healthcare Provider Details

I. General information

NPI: 1811914757
Provider Name (Legal Business Name): ELVIRA KOFMAN D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4110 MOORPARK AVE STE D
SAN JOSE CA
95117-1712
US

IV. Provider business mailing address

4110 MOORPARK AVE STE D
SAN JOSE CA
95117-1712
US

V. Phone/Fax

Practice location:
  • Phone: 408-243-8291
  • Fax: 408-243-0154
Mailing address:
  • Phone: 408-243-8291
  • Fax: 408-243-0154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number45683
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: