Healthcare Provider Details

I. General information

NPI: 1740215870
Provider Name (Legal Business Name): ELISON ORTHODONTICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3357 MERLIN DR
IDAHO FALLS ID
83404-7405
US

IV. Provider business mailing address

3357 MERLIN DR
IDAHO FALLS ID
83404-7405
US

V. Phone/Fax

Practice location:
  • Phone: 208-522-9600
  • Fax: 208-522-9799
Mailing address:
  • Phone: 208-522-9600
  • Fax: 208-522-9799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD1702 OR
License Number StateID

VIII. Authorized Official

Name: DR. JOSEPH H. ELISON
Title or Position: ORTHODONTIST
Credential: D.D.S.,M.S.
Phone: 208-522-9600