Provider Demographics
NPI:1639427230
Name:LEVY, ELODIE
Entity Type:Individual
Prefix:
First Name:ELODIE
Middle Name:
Last Name:LEVY
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 1:2726 E HIGHWAY 190
Mailing Address - Street 2:SUITE 112
Mailing Address - City:COPPERAS COVE
Mailing Address - State:TX
Mailing Address - Zip Code:76522-2522
Mailing Address - Country:US
Mailing Address - Phone:254-542-3500
Mailing Address - Fax:254-542-4013
Practice Address - Street 1:2726 E HIGHWAY 190
Practice Address - Street 2:SUITE 112
Practice Address - City:COPPERAS COVE
Practice Address - State:TX
Practice Address - Zip Code:76522-2522
Practice Address - Country:US
Practice Address - Phone:254-542-3500
Practice Address - Fax:254-542-4013
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX283141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice