Provider Demographics
NPI:1962790592
Name:DEMISSIE, ELIAS (DDS)
Entity type:Individual
Prefix:DR
First Name:ELIAS
Middle Name:
Last Name:DEMISSIE
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 1:7027 ALVERN ST APT 103
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-1970
Mailing Address - Country:US
Mailing Address - Phone:424-443-9598
Mailing Address - Fax:323-771-7722
Practice Address - Street 1:10300 COMPTON AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90002-3628
Practice Address - Country:US
Practice Address - Phone:323-357-6600
Practice Address - Fax:323-771-7722
Is Sole Proprietor?:No
Enumeration Date:2011-07-18
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA61816122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program