Provider Demographics
NPI:1558306142
Name:GHEZZI, ELISA M (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELISA
Middle Name:M
Last Name:GHEZZI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25853 COBBLERS LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-1572
Mailing Address - Country:US
Mailing Address - Phone:248-486-8912
Mailing Address - Fax:
Practice Address - Street 1:6010 W MAPLE RD
Practice Address - Street 2:SUITE 210
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-4406
Practice Address - Country:US
Practice Address - Phone:248-932-8980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010168071223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223G0001XDental ProvidersDentistGeneral Practice
Not Answered122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4125550Medicaid
MI4125531Medicaid
MI4125550Medicaid
MI4125531Medicaid