Provider Demographics
NPI:1306322086
Name:MARIANA C ELWELL DDS FAGD PC
Entity type:Organization
Organization Name:MARIANA C ELWELL DDS FAGD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIANA
Authorized Official - Middle Name:C
Authorized Official - Last Name:ELWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:856-455-4095
Mailing Address - Street 1:3129 COUNTRY LN
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08361-8634
Mailing Address - Country:US
Mailing Address - Phone:856-506-9351
Mailing Address - Fax:
Practice Address - Street 1:6 ATLANTIC ST
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:NJ
Practice Address - Zip Code:08302-1829
Practice Address - Country:US
Practice Address - Phone:856-455-4095
Practice Address - Fax:856-455-5292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-16
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI025828001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1265421986OtherINDIVIDUAL NPI