Provider Demographics
NPI:1699803031
Name:FISHLYN, ELLIOTT HENRY (DDS)
Entity type:Individual
Prefix:
First Name:ELLIOTT
Middle Name:HENRY
Last Name:FISHLYN
Suffix:
Gender:
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4279 SAN RAFAEL AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-3124
Mailing Address - Country:US
Mailing Address - Phone:310-804-7950
Mailing Address - Fax:
Practice Address - Street 1:4279 SAN RAFAEL AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90042-3124
Practice Address - Country:US
Practice Address - Phone:310-804-7950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA249751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice