Provider Demographics
NPI:1215243613
Name:MAYNARD, ELISSA K (DDS)
Entity type:Individual
Prefix:DR
First Name:ELISSA
Middle Name:K
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2690 NE KRESKY AVE
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-2412
Mailing Address - Country:US
Mailing Address - Phone:360-330-9595
Mailing Address - Fax:360-330-9560
Practice Address - Street 1:2690 NE KRESKY AVE
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532
Practice Address - Country:US
Practice Address - Phone:360-330-9595
Practice Address - Fax:360-330-9560
Is Sole Proprietor?:No
Enumeration Date:2010-08-23
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE601787291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice