Provider Demographics
NPI:1144591462
Name:ELISHA, JACOB (DDS)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:ELISHA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11600 WILSHIRE BLVD STE 504
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1788
Mailing Address - Country:US
Mailing Address - Phone:310-231-5100
Mailing Address - Fax:310-231-0024
Practice Address - Street 1:11600 WILSHIRE BLVD STE 504
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1788
Practice Address - Country:US
Practice Address - Phone:310-231-5100
Practice Address - Fax:310-231-0024
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-18
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA362391223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics