Provider Demographics
NPI:1639434665
Name:ELLIOT, EDIOUS K (DMD)
Entity Type:Individual
Prefix:DR
First Name:EDIOUS
Middle Name:K
Last Name:ELLIOT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8240 CAZENOVIA RD STE 60
Mailing Address - Street 2:
Mailing Address - City:MANLIUS
Mailing Address - State:NY
Mailing Address - Zip Code:13104-8814
Mailing Address - Country:US
Mailing Address - Phone:315-692-6546
Mailing Address - Fax:315-692-0449
Practice Address - Street 1:8240 CAZENOVIA RD STE 60
Practice Address - Street 2:
Practice Address - City:MANLIUS
Practice Address - State:NY
Practice Address - Zip Code:13104-8814
Practice Address - Country:US
Practice Address - Phone:315-692-6546
Practice Address - Fax:315-692-0449
Is Sole Proprietor?:No
Enumeration Date:2012-07-05
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ22DI025074001223S0112X
PADA031767207L00000X
PADS0406581223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology