MEDICARE: ELENA MARIE EBRAHIMIAN D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	100343	CA

General Provider Information

NPI Number	:	1023460177
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELENA MARIE EBRAHIMIAN D.D.S.

Provider Business Mailing Address
First Line	:	891 S BASCOM AVE
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95128-2627
Country	:	US
Telephone Number	:	408-298-0777
Fax Number	:

Provider Business Practice Location Address
First Line	:	891 S BASCOM AVE
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95128-2627
Country	:	US
Telephone Number	:	408-298-0777
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2016
Last Update Date	:	07/12/2016

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