=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780466425
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELLIOT PENHASIAN DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2023
-----------------------------------------------------
Last Update Date | 11/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10551 WILSHIRE BLVD APT 402
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90024-4570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-488-3457
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10551 WILSHIRE BLVD APT 402
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90024-4570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-488-3457
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 0909
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------