MEDICARE: DEAN ELATTRACHE DMD MS

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	1223E0200X	Endodontics	0401410744	VA

General Provider Information

NPI Number	:	1043463169
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEAN ELATTRACHE DMD MS

Provider Business Mailing Address
First Line	:	2020 GENERAL BOOTH BLVD
Second Line	:	SUITE 100
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454
Country	:	US
Telephone Number	:	757-427-0144
Fax Number	:	757-427-0145

Provider Business Practice Location Address
First Line	:	2020 GENERAL BOOTH BLVD STE 100
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-5875
Country	:	US
Telephone Number	:	757-427-0144
Fax Number	:	757-427-0145

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

Provider Enumeration Date	:	11/03/2008
Last Update Date	:	11/03/2008

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