Provider Demographics
NPI:1205036290
Name:GROTELL, ELLIOT
Entity Type:Individual
Prefix:
First Name:ELLIOT
Middle Name:
Last Name:GROTELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16510 JAMAICA AVE
Mailing Address - Street 2:
Mailing Address - City:QUEENS
Mailing Address - State:NY
Mailing Address - Zip Code:11432
Mailing Address - Country:US
Mailing Address - Phone:718-206-4088
Mailing Address - Fax:
Practice Address - Street 1:21518 HILLSIDE AVE
Practice Address - Street 2:QUEENS VILLAGE
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:11427
Practice Address - Country:US
Practice Address - Phone:718-740-3951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-19
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0244761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02249470Medicaid