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General NPI Number Information
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NPI Number | 1114063674
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Entity Type | Organization
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Legal Business Name | ELAINE GRACE G ELLORIN DMD INC
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Dates
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Enumeration Date | 01/30/2007
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Last Update Date | 03/20/2012
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Provider Practice Location Address
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Address Line | 911B EAST DUANE AVE
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City | SUNNYVALE
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State | CA
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Zip | 94085-3438
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Country | US
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Telephone | 408-736-7299
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Fax | 408-736-7298
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Provider Business Mailing Address
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Address Line | 911B E DUANE AVE
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City | SUNNYVALE
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State | CA
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Zip | 94085-3438
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Country | US
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Telephone | 408-736-7299
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Fax | 408-736-7298
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER DENTIST
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Name | DR. ELAINE GRACE GACUSAN ELLORIN
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Credential | DMD
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Telephone | 408-736-7299
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 46788
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License Number State | CA
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