Provider Demographics
NPI:1790307684
Name:ELLAITHY, SARA (DMD)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:ELLAITHY
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 1:775 TWIN RIVERS DR N
Mailing Address - Street 2:
Mailing Address - City:EAST WINDSOR
Mailing Address - State:NJ
Mailing Address - Zip Code:08520-5613
Mailing Address - Country:US
Mailing Address - Phone:732-812-1807
Mailing Address - Fax:
Practice Address - Street 1:417 WALL ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:NJ
Practice Address - Zip Code:08540-1504
Practice Address - Country:US
Practice Address - Phone:732-812-1807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-13
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ22DI02823600122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program