Healthcare Provider Details

I. General information

NPI: 1033539085
Provider Name (Legal Business Name): ELEY FAMILY DENTISTRY, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2014
Last Update Date: 09/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 W EAU GALLIE BLVD SUITE #102
MELBOURNE FL
32935-3120
US

IV. Provider business mailing address

2301 W EAU GALLIE BLVD SUITE #102
MELBOURNE FL
32935-3120
US

V. Phone/Fax

Practice location:
  • Phone: 321-622-8711
  • Fax: 321-622-8712
Mailing address:
  • Phone: 321-622-8711
  • Fax: 321-622-8712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN19369
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN22269
License Number StateGA

VIII. Authorized Official

Name: DR. DANIEL WARREN ELEY
Title or Position: PRESIDENT
Credential: D.M.D.
Phone: 321-622-8711