Provider Demographics
NPI:1740775329
Name:ELAPUNKAL, ROSE J (DMD)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:J
Last Name:ELAPUNKAL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2082 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-3033
Mailing Address - Country:US
Mailing Address - Phone:630-607-4623
Mailing Address - Fax:
Practice Address - Street 1:7760 W DEVON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-1500
Practice Address - Country:US
Practice Address - Phone:773-775-2210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-26
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0316841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice