Healthcare Provider Details

I. General information

NPI: 1366128555
Provider Name (Legal Business Name): ELLIOT EZRA HADDAD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2023
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10371 PARKGLENN WAY STE 250
PARKER CO
80138-3871
US

IV. Provider business mailing address

345 E 24TH ST
NEW YORK NY
10010-4020
US

V. Phone/Fax

Practice location:
  • Phone: 303-840-1900
  • Fax:
Mailing address:
  • Phone: 212-998-9800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN.00206709
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: