MEDICARE: ELISON ORTHODONTICS PLLC

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	D1702 OR	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000010012467	OTHER	ID	BLUE SHIELD OF IDAHO
2	1634056	OTHER	ID	UNITED CONCORDIA

General Provider Information

NPI Number	:	1740215870
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELISON ORTHODONTICS PLLC

Provider Business Mailing Address
First Line	:	3357 MERLIN DR
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-7405
Country	:	US
Telephone Number	:	208-522-9600
Fax Number	:	208-522-9799

Provider Business Practice Location Address
First Line	:	3357 MERLIN DR
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-7405
Country	:	US
Telephone Number	:	208-522-9600
Fax Number	:	208-522-9799

Authorized Official
Title or Position	:	ORTHODONTIST
Name	:	DR. JOSEPH H. ELISON
Credential	:	D.D.S.,M.S.
Telephone Number	:	208-522-9600

Provider Enumeration Date	:	07/11/2006
Last Update Date	:	08/22/2020

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Directions to “ELISON ORTHODONTICS PLLC ” Practice Location

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