Healthcare Provider Details

I. General information

NPI: 1083857783
Provider Name (Legal Business Name): RIINA ELSEY DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: RIINA LOBANOV

II. Dates (important events)

Enumeration Date: 04/09/2009
Last Update Date: 03/23/2022
Certification Date: 03/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E LEHIGH AVE PEDIATRIC DENTISTRY RESIDENCY PROGRAM
PHILADELPHIA PA
19125-1012
US

IV. Provider business mailing address

770 MILES RD
WEST CHESTER PA
19380-1950
US

V. Phone/Fax

Practice location:
  • Phone: 215-707-1020
  • Fax: 215-707-0083
Mailing address:
  • Phone: 609-792-3237
  • Fax: 609-792-3237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDL10076
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDS038217
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: