Healthcare Provider Details

I. General information

NPI: 1881602878
Provider Name (Legal Business Name): PAUL STEWART ELLIOTT DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 06/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PARK LANE CENTER
DOUGLASSVILLE PA
19518
US

IV. Provider business mailing address

1 PARK LANE CENTER
DOUGLASSVILLE PA
19518
US

V. Phone/Fax

Practice location:
  • Phone: 610-385-7403
  • Fax: 610-385-7558
Mailing address:
  • Phone: 610-385-7403
  • Fax: 610-385-7558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS025325L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: