Provider Demographics
NPI:1407917552
Name:HEARD, ELISSA (DMD)
Entity Type:Individual
Prefix:DR
First Name:ELISSA
Middle Name:
Last Name:HEARD
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:ELISSA
Other - Middle Name:
Other - Last Name:RICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:111 WILLARD ST
Mailing Address - Street 2:1B
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169
Mailing Address - Country:US
Mailing Address - Phone:617-471-8640
Mailing Address - Fax:617-471-9328
Practice Address - Street 1:111 WILLARD ST
Practice Address - Street 2:1B
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169
Practice Address - Country:US
Practice Address - Phone:617-471-8640
Practice Address - Fax:617-471-8640
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA136711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
4983OtherBCBS
1131OtherDELTA