MEDICARE: ELLIOT PENHASIAN DDS

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	1223G0001X	General Practice Dentistry	109465	CA

General Provider Information

NPI Number	:	1780466425
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLIOT PENHASIAN DDS

Provider Business Mailing Address
First Line	:	12026 RHODE ISLAND AVE APT 102
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-1357
Country	:	US
Telephone Number	:	310-488-3457
Fax Number	:

Provider Business Practice Location Address
First Line	:	12013 WILSHIRE BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-1201
Country	:	US
Telephone Number	:	310-219-6039
Fax Number	:

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

Provider Enumeration Date	:	10/17/2023
Last Update Date	:	06/01/2026

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Directions to “ ELLIOT PENHASIAN DDS” Practice Location

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