Provider Demographics
NPI:1548505324
Name:ELIHU, MICHELLE CIVIA (DDS)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:CIVIA
Last Name:ELIHU
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 RUE GRAND DUCAL
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-5906
Mailing Address - Country:US
Mailing Address - Phone:949-283-3419
Mailing Address - Fax:
Practice Address - Street 1:12223 HIGHLAND AVE STE 108
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91739-2574
Practice Address - Country:US
Practice Address - Phone:909-463-7890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-04
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61963122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist