Provider Demographics
NPI:1508579384
Name:DACK, ELISA (RDH)
Entity Type:Individual
Prefix:MRS
First Name:ELISA
Middle Name:
Last Name:DACK
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 806
Mailing Address - Street 2:
Mailing Address - City:WEST BRANCH
Mailing Address - State:MI
Mailing Address - Zip Code:48661-0806
Mailing Address - Country:US
Mailing Address - Phone:989-965-1652
Mailing Address - Fax:
Practice Address - Street 1:630 PROGRESS ST
Practice Address - Street 2:
Practice Address - City:WEST BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48661-8603
Practice Address - Country:US
Practice Address - Phone:989-345-5020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-27
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902012908124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist