MEDICARE: DR. ELONIA LASKU D.D.S.

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	5681	AZ

General Provider Information

NPI Number	:	1861510737
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELONIA LASKU D.D.S.

Provider Business Mailing Address
First Line	:	3716 E. MAFFEO RD,
Second Line	:
City	:	PHONIX
State	:	AZ
Zip	:	85050
Country	:	US
Telephone Number	:	480-940-5140
Fax Number	:

Provider Business Practice Location Address
First Line	:	6605 N 19TH AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85015-1628
Country	:	US
Telephone Number	:	602-242-9077
Fax Number	:

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

Provider Enumeration Date	:	03/27/2007
Last Update Date	:	07/08/2007

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