Healthcare Provider Details

I. General information

NPI: 1942728241
Provider Name (Legal Business Name): ELLEFSON & MARELICH DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2017
Last Update Date: 09/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 SONOMA AVE SUITE A
SANTA ROSA CA
95405
US

IV. Provider business mailing address

1100 SONOMA AVE SUITE A
SANTA ROSA CA
95405
US

V. Phone/Fax

Practice location:
  • Phone: 707-527-0363
  • Fax: 707-527-6735
Mailing address:
  • Phone: 707-527-0363
  • Fax: 707-527-6735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDDS100710
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: LAURA DAVID ELLEFSON
Title or Position: DENTIST
Credential: DMD
Phone: 707-527-0363