Provider Demographics
NPI:1356796551
Name:YOSSEFI, ELAD
Entity type:Individual
Prefix:
First Name:ELAD
Middle Name:
Last Name:YOSSEFI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:454 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851-1063
Mailing Address - Country:US
Mailing Address - Phone:203-364-5084
Mailing Address - Fax:
Practice Address - Street 1:454 MAIN AVE
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851-1063
Practice Address - Country:US
Practice Address - Phone:203-364-5084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-26
Last Update Date:2020-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT11713122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program