Healthcare Provider Details

I. General information

NPI: 1407239031
Provider Name (Legal Business Name): ELYSE PATRELLA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2015
Last Update Date: 03/02/2026
Certification Date: 03/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N OCEAN AVE
PATCHOGUE NY
11772-2004
US

IV. Provider business mailing address

101 ABBEY ST
MASSAPEQUA PARK NY
11762-3426
US

V. Phone/Fax

Practice location:
  • Phone: 631-289-1919
  • Fax:
Mailing address:
  • Phone: 516-468-2374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number058795
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: