Healthcare Provider Details

I. General information

NPI: 1154237337
Provider Name (Legal Business Name): ELITE GUM CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3751 WINFORD DR
TARZANA CA
91356-5810
US

IV. Provider business mailing address

3751 WINFORD DR
TARZANA CA
91356-5810
US

V. Phone/Fax

Practice location:
  • Phone: 310-409-3071
  • Fax:
Mailing address:
  • Phone: 310-409-3071
  • 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: JERRY SIDERMAN
Title or Position: OWNER
Credential: DDS
Phone: 310-409-3071