Provider Demographics
NPI:1083774285
Name:ELSON, STACIE ANNE (RDA)
Entity Type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:ANNE
Last Name:ELSON
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 COFFEE RD STE 9A
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4228
Mailing Address - Country:US
Mailing Address - Phone:209-571-7283
Mailing Address - Fax:209-571-7285
Practice Address - Street 1:1130 COFFEE RD STE 9A
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-4228
Practice Address - Country:US
Practice Address - Phone:209-571-7283
Practice Address - Fax:209-571-7285
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29984126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant