Provider Demographics
NPI:1962631549
Name:GOSNELL, ELIZABETH SUTTON (DMD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:SUTTON
Last Name:GOSNELL
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 1:3333 BURNET AVE
Mailing Address - Street 2:DIVISION OF PEDIATRIC DENTISTRY
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3026
Mailing Address - Country:US
Mailing Address - Phone:513-636-4644
Mailing Address - Fax:
Practice Address - Street 1:3333 BURNET AVE
Practice Address - Street 2:DIVISION OF PEDIATRIC DENTISTRY
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3026
Practice Address - Country:US
Practice Address - Phone:513-636-4644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-05
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0229941223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3104876Medicaid