Provider Demographics
NPI:1093815250
Name:ELY, DOUGLAS SCOTT (DMD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:SCOTT
Last Name:ELY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:373 VOSSELLER AVE
Mailing Address - Street 2:
Mailing Address - City:BOUND BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:08805-1604
Mailing Address - Country:US
Mailing Address - Phone:732-469-6662
Mailing Address - Fax:732-469-4182
Practice Address - Street 1:373 VOSSELLER AVE
Practice Address - Street 2:
Practice Address - City:BOUND BROOK
Practice Address - State:NJ
Practice Address - Zip Code:08805-1604
Practice Address - Country:US
Practice Address - Phone:732-469-6662
Practice Address - Fax:732-469-4182
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI01607300122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist