Provider Demographics
NPI:1083803233
Name:MAMMEN, ELSA (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELSA
Middle Name:
Last Name:MAMMEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7770 W GRAND PKWY S
Mailing Address - Street 2:STE E
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77406-5832
Mailing Address - Country:US
Mailing Address - Phone:281-713-4990
Mailing Address - Fax:
Practice Address - Street 1:7770 W GRAND PKWY S
Practice Address - Street 2:STE E
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77406-5832
Practice Address - Country:US
Practice Address - Phone:281-713-4990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-23
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX263581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02885587Medicare PIN