Provider Demographics
NPI:1033539085
Name:ELEY FAMILY DENTISTRY, P.A.
Entity Type:Organization
Organization Name:ELEY FAMILY DENTISTRY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:WARREN
Authorized Official - Last Name:ELEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:321-622-8711
Mailing Address - Street 1:2301 W EAU GALLIE BLVD
Mailing Address - Street 2:SUITE #102
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-3120
Mailing Address - Country:US
Mailing Address - Phone:321-622-8711
Mailing Address - Fax:321-622-8712
Practice Address - Street 1:2301 W EAU GALLIE BLVD
Practice Address - Street 2:SUITE #102
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-3120
Practice Address - Country:US
Practice Address - Phone:321-622-8711
Practice Address - Fax:321-622-8712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-17
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN19369122300000X
GADN222691223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty