Provider Demographics
NPI:1518318401
Name:ELJACK, HAITHAM (DMD)
Entity Type:Individual
Prefix:DR
First Name:HAITHAM
Middle Name:
Last Name:ELJACK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6008 CAROLINE DR
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33545-4138
Mailing Address - Country:US
Mailing Address - Phone:618-559-7259
Mailing Address - Fax:
Practice Address - Street 1:7650 GALL BLVD
Practice Address - Street 2:
Practice Address - City:ZEPHYRHILLS
Practice Address - State:FL
Practice Address - Zip Code:33541-4313
Practice Address - Country:US
Practice Address - Phone:813-364-5890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-22
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN237751223G0001X
MI2901021990122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist