Provider Demographics
NPI:1679864730
Name:ELISON, TRACI WASIATH (DDS)
Entity Type:Individual
Prefix:MS
First Name:TRACI
Middle Name:WASIATH
Last Name:ELISON
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 1:11301 WOOD RIVER WAY
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-7314
Mailing Address - Country:US
Mailing Address - Phone:406-202-1920
Mailing Address - Fax:
Practice Address - Street 1:4315 DIPLOMACY DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5926
Practice Address - Country:US
Practice Address - Phone:907-563-2662
Practice Address - Fax:907-563-2662
Is Sole Proprietor?:No
Enumeration Date:2011-04-25
Last Update Date:2013-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTDEN-DEN-LIC-4169122300000X
WADE 60284737122300000X
AK1502122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist