Provider Demographics
NPI:1811482565
Name:ELAN LAKE LANSING
Entity type:Organization
Organization Name:ELAN LAKE LANSING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MBR
Authorized Official - Prefix:DR
Authorized Official - First Name:MAURICIO
Authorized Official - Middle Name:
Authorized Official - Last Name:MOELLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:734-276-2541
Mailing Address - Street 1:818 W LAKE LANSING RD
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-1308
Mailing Address - Country:US
Mailing Address - Phone:517-333-9500
Mailing Address - Fax:
Practice Address - Street 1:818 W LAKE LANSING RD
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-1308
Practice Address - Country:US
Practice Address - Phone:517-333-9500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-26
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI18235261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental