Provider Demographics
NPI:1225259856
Name:DEROS, ELIAS CONSTANTINE (DMD)
Entity Type:Individual
Prefix:DR
First Name:ELIAS
Middle Name:CONSTANTINE
Last Name:DEROS
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 1:22 LISBON STREET
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06795
Mailing Address - Country:US
Mailing Address - Phone:203-755-4403
Mailing Address - Fax:203-574-3388
Practice Address - Street 1:80 PHOENIX AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702
Practice Address - Country:US
Practice Address - Phone:203-755-4403
Practice Address - Fax:203-574-3388
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8029122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist