Provider Demographics
NPI:1215357892
Name:ELIASON, JOSEPH (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:
Last Name:ELIASON
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1880 SONOMA AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4953
Mailing Address - Country:US
Mailing Address - Phone:707-546-4883
Mailing Address - Fax:
Practice Address - Street 1:1880 SONOMA AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4953
Practice Address - Country:US
Practice Address - Phone:707-546-4883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-22
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA645531223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics