MEDICARE: EDOUARD ETLIS DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	047627	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013937416
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDOUARD ETLIS DDS

Provider Business Mailing Address
First Line	:	3030 OCEAN AVE
Second Line	:	SUITE AA
City	:	BROOKLYN
State	:	NY
Zip	:	11235-3363
Country	:	US
Telephone Number	:	718-769-5379
Fax Number	:	718-769-2365

Provider Business Practice Location Address
First Line	:	3030 OCEAN AVE
Second Line	:	SUITE AA
City	:	BROOKLYN
State	:	NY
Zip	:	11235-3363
Country	:	US
Telephone Number	:	718-769-5379
Fax Number	:	718-769-2365

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	07/08/2007

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