Provider Demographics
NPI:1033309067
Name:ELIAS C DEROS DMD LLC
Entity Type:Organization
Organization Name:ELIAS C DEROS DMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIAS
Authorized Official - Middle Name:C
Authorized Official - Last Name:DEROS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:203-755-4403
Mailing Address - Street 1:80 PHOENIX AVE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06702
Mailing Address - Country:US
Mailing Address - Phone:203-755-4403
Mailing Address - Fax:203-574-3388
Practice Address - Street 1:80 PHOENIX AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702
Practice Address - Country:US
Practice Address - Phone:203-755-4403
Practice Address - Fax:203-574-3388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-26
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8029122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty