Provider Demographics
NPI:1154747541
Name:WAEL M. ELOSTA PLLC
Entity type:Organization
Organization Name:WAEL M. ELOSTA PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ELOSTA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-221-4222
Mailing Address - Street 1:19415 DEERFIELD AVE STE 309
Mailing Address - Street 2:
Mailing Address - City:LANSDOWNE
Mailing Address - State:VA
Mailing Address - Zip Code:20176-8472
Mailing Address - Country:US
Mailing Address - Phone:703-729-1818
Mailing Address - Fax:
Practice Address - Street 1:19415 DEERFIELD AVE STE 309
Practice Address - Street 2:
Practice Address - City:LANSDOWNE
Practice Address - State:VA
Practice Address - Zip Code:20176-8472
Practice Address - Country:US
Practice Address - Phone:703-729-1818
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-10
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401412058261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental