Provider Demographics
NPI:1427595164
Name:ELAN DENTAL GROUP LANSING, PLLC
Entity Type:Organization
Organization Name:ELAN DENTAL GROUP LANSING, PLLC
Other - Org Name:ELAN DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:SERGIO
Authorized Official - Middle Name:MAURICIO
Authorized Official - Last Name:MOELLER ZEVALLOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:734-662-7874
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:734-662-1518
Practice Address - Street 1:1500 ABBOTT RD STE 120
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-1956
Practice Address - Country:US
Practice Address - Phone:517-351-9540
Practice Address - Fax:517-351-1645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-19
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI18235261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental