Provider Demographics
NPI:1275101552
Name:HUMISTON, ELLIOT VINCENT (DDS)
Entity Type:Individual
Prefix:
First Name:ELLIOT
Middle Name:VINCENT
Last Name:HUMISTON
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 1:1337 N TAYLOR DR
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-3012
Mailing Address - Country:US
Mailing Address - Phone:920-452-4688
Mailing Address - Fax:
Practice Address - Street 1:1337 N TAYLOR DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-3012
Practice Address - Country:US
Practice Address - Phone:920-452-4688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002549-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice