Provider Demographics
NPI:1588838692
Name:BAN, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:BAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:935 HOMESTEAD AVE
Mailing Address - Street 2:
Mailing Address - City:MAYBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:12543-1311
Mailing Address - Country:US
Mailing Address - Phone:845-427-5419
Mailing Address - Fax:
Practice Address - Street 1:935 HOMESTEAD AVE
Practice Address - Street 2:
Practice Address - City:MAYBROOK
Practice Address - State:NY
Practice Address - Zip Code:12543-1311
Practice Address - Country:US
Practice Address - Phone:845-427-5419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-18
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040569-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice