Provider Demographics
NPI:1124158548
Name:ELISON, JIMMY K (DMD)
Entity type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:K
Last Name:ELISON
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:PO BOX 410
Mailing Address - Street 2:
Mailing Address - City:NEAH BAY
Mailing Address - State:WA
Mailing Address - Zip Code:98357-0410
Mailing Address - Country:US
Mailing Address - Phone:360-645-2233
Mailing Address - Fax:360-645-2305
Practice Address - Street 1:250 FORT STREET
Practice Address - Street 2:
Practice Address - City:NEAH BAY
Practice Address - State:WA
Practice Address - Zip Code:98357
Practice Address - Country:US
Practice Address - Phone:360-645-2233
Practice Address - Fax:360-645-2305
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN00822122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist