Provider Demographics
NPI:1922136092
Name:ELAM, CHRISTINE GUTIERREZ (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:GUTIERREZ
Last Name:ELAM
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 1:66 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRONSON
Mailing Address - State:FL
Mailing Address - Zip Code:32621-6338
Mailing Address - Country:US
Mailing Address - Phone:352-486-5300
Mailing Address - Fax:352-486-5307
Practice Address - Street 1:66 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BRONSON
Practice Address - State:FL
Practice Address - Zip Code:32621-6338
Practice Address - Country:US
Practice Address - Phone:352-486-5300
Practice Address - Fax:352-486-5307
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 154161223P0221X
FLDN154161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL075720900Medicaid
FLBG 7022863OtherDEA