Healthcare Provider Details

I. General information

NPI: 1639434665
Provider Name (Legal Business Name): EDIOUS K. ELLIOT DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2012
Last Update Date: 07/06/2021
Certification Date: 07/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8240 CAZENOVIA RD STE 60
MANLIUS NY
13104-8814
US

IV. Provider business mailing address

8240 CAZENOVIA RD STE 60
MANLIUS NY
13104-8814
US

V. Phone/Fax

Practice location:
  • Phone: 315-692-6546
  • Fax: 315-692-0449
Mailing address:
  • Phone: 315-692-6546
  • Fax: 315-692-0449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number22DI02507400
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberDA031767
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS040658
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: