1427595164 NPI number — ELAN DENTAL GROUP LANSING, PLLC

Table of content: (NPI 1427595164)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427595164 NPI number — ELAN DENTAL GROUP LANSING, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELAN DENTAL GROUP LANSING, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427595164
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2509 S STATE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANN ARBOR
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48104-6145
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-662-7874
Provider Business Mailing Address Fax Number:
734-662-1518

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 ABBOTT RD STE 120
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST LANSING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48823-1956
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-351-9540
Provider Business Practice Location Address Fax Number:
517-351-1645
Provider Enumeration Date:
01/19/2017

Additional Information

Authorized Official

Authorized Official Last Name:
MOELLER ZEVALLOS
Authorized Official First Name:
SERGIO
Authorized Official Middle Name:
MAURICIO
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
734-662-7874

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  18235 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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