Provider Demographics
NPI:1225550528
Name:DESAMERO, ELIZABETH NICOLE (DMD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:NICOLE
Last Name:DESAMERO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9716 N 151ST ST
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:NE
Mailing Address - Zip Code:68007-1651
Mailing Address - Country:US
Mailing Address - Phone:314-607-4876
Mailing Address - Fax:
Practice Address - Street 1:140 E 22ND ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-2667
Practice Address - Country:US
Practice Address - Phone:402-727-4400
Practice Address - Fax:402-727-4404
Is Sole Proprietor?:No
Enumeration Date:2017-07-09
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20170235941223G0001X
NE74851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice