Provider Demographics
NPI:1467835272
Name:ELMARIAH, TEJAN KHALDON OTTALLAH (DMD)
Entity Type:Individual
Prefix:
First Name:TEJAN
Middle Name:KHALDON OTTALLAH
Last Name:ELMARIAH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 LANCASTER ST
Mailing Address - Street 2:# 100
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21231-3584
Mailing Address - Country:US
Mailing Address - Phone:410-970-0440
Mailing Address - Fax:
Practice Address - Street 1:1820 LANCASTER ST
Practice Address - Street 2:# 100
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21231-3584
Practice Address - Country:US
Practice Address - Phone:410-970-0440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-30
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16093122300000X
FL21314122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist