Provider Demographics
NPI:1225248230
Name:ELYSON, MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:ELYSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19642 VENTURA BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-7125
Mailing Address - Country:US
Mailing Address - Phone:818-708-1112
Mailing Address - Fax:
Practice Address - Street 1:19642 VENTURA BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-7125
Practice Address - Country:US
Practice Address - Phone:818-708-1112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40234122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist