Provider Demographics
NPI:1396051439
Name:ELITE ORTHODONTICS, LLC
Entity type:Organization
Organization Name:ELITE ORTHODONTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:EMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:ABDALLAH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:781-686-1733
Mailing Address - Street 1:107 EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-4515
Mailing Address - Country:US
Mailing Address - Phone:781-686-1733
Mailing Address - Fax:781-686-1726
Practice Address - Street 1:107 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-4515
Practice Address - Country:US
Practice Address - Phone:781-686-1733
Practice Address - Fax:781-686-1726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-26
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA216551223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty