Provider Demographics
NPI:1336242296
Name:PERKS, ELIZAZETH (DMD)
Entity Type:Individual
Prefix:
First Name:ELIZAZETH
Middle Name:
Last Name:PERKS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:PEREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:2849 CHANCERY LN STE 106
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-1427
Mailing Address - Country:US
Mailing Address - Phone:813-422-2599
Mailing Address - Fax:813-422-2599
Practice Address - Street 1:3115 W COLUMBUS DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-1865
Practice Address - Country:US
Practice Address - Phone:813-422-2599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN155301223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014265500Medicaid
FL070691400Medicaid