Provider Demographics
NPI:1124031612
Name:ELITT, DONALD G (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:G
Last Name:ELITT
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4585 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-5858
Mailing Address - Country:US
Mailing Address - Phone:314-837-4800
Mailing Address - Fax:
Practice Address - Street 1:4585 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-5858
Practice Address - Country:US
Practice Address - Phone:314-837-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO119931223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO11993OtherSTATE LICENSE NUMBER