Provider Demographics
NPI:1174698963
Name:NELSON, ELISA B (DDS)
Entity type:Individual
Prefix:
First Name:ELISA
Middle Name:B
Last Name:NELSON
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 1:283 COMMACK RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-6021
Mailing Address - Country:US
Mailing Address - Phone:631-499-7001
Mailing Address - Fax:631-499-1830
Practice Address - Street 1:283 COMMACK RD
Practice Address - Street 2:SUITE 130
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-6021
Practice Address - Country:US
Practice Address - Phone:631-499-7001
Practice Address - Fax:631-499-1830
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0445281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice