Provider Demographics
NPI:1639699010
Name:SOULLIERE, ELISE CHANTEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELISE
Middle Name:CHANTEL
Last Name:SOULLIERE
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 1:2222 COURT ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-4938
Mailing Address - Country:US
Mailing Address - Phone:810-841-8966
Mailing Address - Fax:
Practice Address - Street 1:2837 STABLE DR
Practice Address - Street 2:
Practice Address - City:KIMBALL
Practice Address - State:MI
Practice Address - Zip Code:48074-1441
Practice Address - Country:US
Practice Address - Phone:810-985-3301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-26
Last Update Date:2017-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010223581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice