Provider Demographics
NPI:1922029776
Name:BRILLIANT, ELLIOTT WARREN (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELLIOTT
Middle Name:WARREN
Last Name:BRILLIANT
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 1:10 MEDICAL PLZ
Mailing Address - Street 2:SUITE 203
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-2193
Mailing Address - Country:US
Mailing Address - Phone:516-759-0086
Mailing Address - Fax:
Practice Address - Street 1:10 MEDICAL PLZ
Practice Address - Street 2:SUITE 203
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-2193
Practice Address - Country:US
Practice Address - Phone:516-759-0086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY29750122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist