MEDICARE: DR. ELISA M. GHEZZI DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	2901016807	MI
2	122300000X	Dentist	2901016807	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558306142
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELISA M. GHEZZI DDS

Provider Business Mailing Address
First Line	:	25853 COBBLERS LN
Second Line	:
City	:	SOUTH LYON
State	:	MI
Zip	:	48178-1572
Country	:	US
Telephone Number	:	248-486-8912
Fax Number	:

Provider Business Practice Location Address
First Line	:	6010 W MAPLE RD
Second Line	:	SUITE 210
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48322-4406
Country	:	US
Telephone Number	:	248-932-8980
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/18/2006
Last Update Date	:	09/11/2025

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