Healthcare Provider Details

I. General information

NPI: 1699619163
Provider Name (Legal Business Name): DAVID ELYASI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2026
Last Update Date: 04/16/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE
HACKENSACK NJ
07601-1915
US

IV. Provider business mailing address

252 10TH ST
BETHPAGE NY
11714-1723
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-3492
  • Fax: 551-996-0819
Mailing address:
  • Phone: 516-508-1119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberNA
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: