Provider Demographics
NPI:1174052047
Name:COLLEDGE, ELISSA DIANE (DDS)
Entity type:Individual
Prefix:
First Name:ELISSA
Middle Name:DIANE
Last Name:COLLEDGE
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 1:1818 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602-3558
Mailing Address - Country:US
Mailing Address - Phone:814-232-7464
Mailing Address - Fax:
Practice Address - Street 1:2217 7TH AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-2243
Practice Address - Country:US
Practice Address - Phone:814-931-9111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-05
Last Update Date:2017-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0413161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice