Provider Demographics
NPI:1588700181
Name:ELVIN, JOHN RICHARD (LD)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:RICHARD
Last Name:ELVIN
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:292 CHEHALIS VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532
Mailing Address - Country:US
Mailing Address - Phone:360-259-9157
Mailing Address - Fax:
Practice Address - Street 1:292 CHEHALIS VALLEY RD
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532
Practice Address - Country:US
Practice Address - Phone:360-259-9157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN00000197122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist