Provider Demographics
NPI:1285377390
Name:LEVERETT, ELIJAH (DMD)
Entity type:Individual
Prefix:
First Name:ELIJAH
Middle Name:
Last Name:LEVERETT
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 1:17 SPRING ST APT 1
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-5122
Mailing Address - Country:US
Mailing Address - Phone:207-712-9779
Mailing Address - Fax:
Practice Address - Street 1:25 STONE ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-6114
Practice Address - Country:US
Practice Address - Phone:207-622-9210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-16
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDEN50381223G0001X
MADL15242390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes1223G0001XDental ProvidersDentistGeneral Practice