Provider Demographics
NPI:1255356598
Name:ELIAS, NIDAL S (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:NIDAL
Middle Name:S
Last Name:ELIAS
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9250 BAYMEADOWS RD
Mailing Address - Street 2:SUITE #300
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-1883
Mailing Address - Country:US
Mailing Address - Phone:904-731-2120
Mailing Address - Fax:904-731-9235
Practice Address - Street 1:9250 BAYMEADOWS RD
Practice Address - Street 2:SUITE #300
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-1883
Practice Address - Country:US
Practice Address - Phone:904-731-2120
Practice Address - Fax:904-731-9235
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11583122300000X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59-3051738OtherFEDERAL TAX I. D. NUMBER
FL63500AMedicare ID - Type UnspecifiedMEDICARE #