Provider Demographics
NPI:1467003160
Name:ELEVATION DENTAL STUDIO, DMD, P.C.
Entity Type:Organization
Organization Name:ELEVATION DENTAL STUDIO, DMD, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MITZ-ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:EDMOND
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:914-259-8559
Mailing Address - Street 1:545 GRAMATAN AVE UNIT B
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10552-2103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:545 GRAMATAN AVE UNIT B
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10552-2103
Practice Address - Country:US
Practice Address - Phone:914-259-8559
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03232928Medicaid
1740516525OtherINDIVIDUAL NPI
DCFA1738890OtherDEA