Provider Demographics
NPI:1790511020
Name:EISA, ELFATIH
Entity type:Individual
Prefix:
First Name:ELFATIH
Middle Name:
Last Name:EISA
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 1:8 SUNSET HILLS PROFESSIONAL CTR
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-3760
Mailing Address - Country:US
Mailing Address - Phone:202-957-2324
Mailing Address - Fax:
Practice Address - Street 1:8 SUNSET HILLS PROFESSIONAL CTR
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-3760
Practice Address - Country:US
Practice Address - Phone:618-831-8041
Practice Address - Fax:618-831-8042
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-12
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.035367122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist