Provider Demographics
NPI:1073069548
Name:ELASSAL, PHILLIP (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:
Last Name:ELASSAL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8383 S PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-5249
Mailing Address - Country:US
Mailing Address - Phone:405-682-8705
Mailing Address - Fax:
Practice Address - Street 1:8383 S PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-5249
Practice Address - Country:US
Practice Address - Phone:405-682-8705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-25
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6885122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist