Provider Demographics
NPI:1851598593
Name:WITTBOLD, ELSA MARIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELSA
Middle Name:MARIE
Last Name:WITTBOLD
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 1:555 W GRANADA BLVD
Mailing Address - Street 2:SUITE C-2
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-9485
Mailing Address - Country:US
Mailing Address - Phone:386-675-6769
Mailing Address - Fax:386-657-6770
Practice Address - Street 1:555 W GRANADA BLVD
Practice Address - Street 2:SUITE C-2
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-9485
Practice Address - Country:US
Practice Address - Phone:386-675-6769
Practice Address - Fax:386-657-6770
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 18198122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIDT-1511OtherDENTTAL LICENSE
FLDN18198OtherDENTAL LICENSE