Provider Demographics
NPI:1740215870
Name:ELISON ORTHODONTICS PLLC
Entity Type:Organization
Organization Name:ELISON ORTHODONTICS PLLC
Other - Org Name:JOSEPH H. ELISON AND/OR JOSEPH MATTHEW ELISON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:H
Authorized Official - Last Name:ELISON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MS
Authorized Official - Phone:208-522-9600
Mailing Address - Street 1:3357 MERLIN DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7405
Mailing Address - Country:US
Mailing Address - Phone:208-522-9600
Mailing Address - Fax:208-522-9799
Practice Address - Street 1:3357 MERLIN DR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7405
Practice Address - Country:US
Practice Address - Phone:208-522-9600
Practice Address - Fax:208-522-9799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD1702 OR1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010012467OtherBLUE SHIELD OF IDAHO
ID1634056OtherUNITED CONCORDIA