MEDICARE: DR. PHILLIP ELASSAL 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	122300000X	Dentist	6885	OK

General Provider Information

NPI Number	:	1073069548
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PHILLIP ELASSAL DDS

Provider Business Mailing Address
First Line	:	8383 S PENNSYLVANIA AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73159-5249
Country	:	US
Telephone Number	:	405-682-8705
Fax Number	:

Provider Business Practice Location Address
First Line	:	8383 S PENNSYLVANIA AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73159-5249
Country	:	US
Telephone Number	:	405-682-8705
Fax Number	:

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

Provider Enumeration Date	:	08/25/2016
Last Update Date	:	08/25/2016

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