Provider Demographics
NPI:1497843189
Name:ELVECROG, JOHN EUGENE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EUGENE
Last Name:ELVECROG
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 1:17977 LIV LN
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55346-4106
Mailing Address - Country:US
Mailing Address - Phone:952-934-4762
Mailing Address - Fax:
Practice Address - Street 1:8170 OLD CARRIAGE CT
Practice Address - Street 2:SUITE 150
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-3163
Practice Address - Country:US
Practice Address - Phone:952-224-8090
Practice Address - Fax:952-224-8095
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND115271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice