MEDICARE: ELENES DENTAL CORPORATION

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	261QD0000X	Dental Clinic/Center	30715	CA

General Provider Information

NPI Number	:	1841596954
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELENES DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	3127 BALDWIN PARK BLVD
Second Line	:	SUITE D
City	:	BALDWIN PARK
State	:	CA
Zip	:	91706-4754
Country	:	US
Telephone Number	:	626-962-3500
Fax Number	:	626-962-3551

Provider Business Practice Location Address
First Line	:	3127 BALDWIN PARK BLVD
Second Line	:	SUITE D
City	:	BALDWIN PARK
State	:	CA
Zip	:	91706-4754
Country	:	US
Telephone Number	:	626-962-3500
Fax Number	:	626-962-3551

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DANIEL ELENES
Credential	:	D.D.S.
Telephone Number	:	310-637-2600

Provider Enumeration Date	:	02/07/2011
Last Update Date	:	03/01/2011

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