Healthcare Provider Details

I. General information

NPI: 1922125947
Provider Name (Legal Business Name): ANDREA ELENBAAS D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 11/28/2023
Certification Date: 11/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 COURTHOUSE RD STE 103
GULFPORT MS
39507-1889
US

IV. Provider business mailing address

370 COURTHOUSE RD STE 103
GULFPORT MS
39507-1889
US

V. Phone/Fax

Practice location:
  • Phone: 228-203-1700
  • Fax: 228-203-1770
Mailing address:
  • Phone: 228-203-1700
  • Fax: 228-203-1770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2934-96
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License Number2934-96
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: