Provider Demographics
NPI:1255003497
Name:AMM, ELIE WILLIAM (DDS, MS)
Entity Type:Individual
Prefix:
First Name:ELIE
Middle Name:WILLIAM
Last Name:AMM
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-2801
Mailing Address - Country:US
Mailing Address - Phone:617-751-9920
Mailing Address - Fax:
Practice Address - Street 1:930 COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-1274
Practice Address - Country:US
Practice Address - Phone:617-358-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADF117241223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics