MEDICARE: DR. ELIZABETH POLK CONSTANTINO D.M.D.

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	40874	CA

General Provider Information

NPI Number	:	1679575468
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELIZABETH POLK CONSTANTINO D.M.D.

Provider Business Mailing Address
First Line	:	1815 E WORKMAN AVE STE A
Second Line	:
City	:	WEST COVINA
State	:	CA
Zip	:	91791-1423
Country	:	US
Telephone Number	:	626-966-7150
Fax Number	:	626-966-7150

Provider Business Practice Location Address
First Line	:	1815 E WORKMAN AVE STE A
Second Line	:
City	:	WEST COVINA
State	:	CA
Zip	:	91791-1423
Country	:	US
Telephone Number	:	626-966-7150
Fax Number	:	626-966-7150

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

Provider Enumeration Date	:	08/11/2005
Last Update Date	:	12/21/2010

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