MEDICARE: DR. ANDREA ELENBAAS D.M.D.

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	1223X2210X	Orofacial Pain Dentistry	2934-96	MS
2	1223G0001X	General Practice Dentistry	2934-96	MS

General Provider Information

NPI Number	:	1922125947
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANDREA ELENBAAS D.M.D.

Provider Business Mailing Address
First Line	:	370 COURTHOUSE RD STE 103
Second Line	:
City	:	GULFPORT
State	:	MS
Zip	:	39507-1889
Country	:	US
Telephone Number	:	228-203-1700
Fax Number	:	228-203-1770

Provider Business Practice Location Address
First Line	:	370 COURTHOUSE RD STE 103
Second Line	:
City	:	GULFPORT
State	:	MS
Zip	:	39507-1889
Country	:	US
Telephone Number	:	228-203-1700
Fax Number	:	228-203-1770

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

Provider Enumeration Date	:	03/23/2007
Last Update Date	:	11/28/2023

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