1538571005 NPI number — DR. ELISSA LAUREN TEASDALE DMD

Table of content: DR. ELISSA LAUREN TEASDALE DMD (NPI 1538571005)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538571005 NPI number — DR. ELISSA LAUREN TEASDALE DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TEASDALE
Provider First Name:
ELISSA
Provider Middle Name:
LAUREN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1538571005
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 MILLSTREAM LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PENACOOK
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03303-1819
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-738-1308
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 TANNER FORD BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HANAHAN
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29410-4707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-818-5437
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/02/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  DGD.8377 GD , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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