Provider Demographics
NPI:1669888079
Name:ED, ELIJAH (DMD)
Entity type:Individual
Prefix:DR
First Name:ELIJAH
Middle Name:
Last Name:ED
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 E END AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15221-2727
Mailing Address - Country:US
Mailing Address - Phone:814-341-7072
Mailing Address - Fax:
Practice Address - Street 1:1789 S BRADDOCK AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15218-1842
Practice Address - Country:US
Practice Address - Phone:412-242-4022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-07
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS040035122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist