Provider Demographics
NPI:1750311684
Name:ELIASSEN, JOHN C (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
Last Name:ELIASSEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 10TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT ROYAL
Mailing Address - State:SC
Mailing Address - Zip Code:29935-2422
Mailing Address - Country:US
Mailing Address - Phone:843-521-7733
Mailing Address - Fax:
Practice Address - Street 1:719 OKATIE HWY # 170
Practice Address - Street 2:
Practice Address - City:OKATIE
Practice Address - State:SC
Practice Address - Zip Code:29909-3963
Practice Address - Country:US
Practice Address - Phone:843-987-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8167122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX8167Medicaid