Provider Demographics
NPI:1245803295
Name:ELAN OKEMOS LLC
Entity Type:Organization
Organization Name:ELAN OKEMOS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SERGIO
Authorized Official - Middle Name:MAURICIO
Authorized Official - Last Name:MOELLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:734-276-2541
Mailing Address - Street 1:2509 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-6145
Mailing Address - Country:US
Mailing Address - Phone:734-662-7874
Mailing Address - Fax:
Practice Address - Street 1:2445 WOODLAKE CIR
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-5941
Practice Address - Country:US
Practice Address - Phone:734-662-7874
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental