MEDICARE: ELVEBAK ORTHODONTICS, PA

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	20522	TX

General Provider Information

NPI Number	:	1265439699
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELVEBAK ORTHODONTICS, PA

Provider Business Mailing Address
First Line	:	6225 CHAPEL HILL BLVD
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75093-6392
Country	:	US
Telephone Number	:	972-931-2700
Fax Number	:	972-931-2703

Provider Business Practice Location Address
First Line	:	6225 CHAPEL HILL BLVD
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75093-6392
Country	:	US
Telephone Number	:	972-931-2700
Fax Number	:	972-931-2703

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. BRYAN S ELVEBAK
Credential	:	DDS, MS
Telephone Number	:	972-931-2700

Provider Enumeration Date	:	06/30/2005
Last Update Date	:	03/17/2018

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