Provider Demographics
NPI:1316306053
Name:BARNETT, ELYSSA DAWN
Entity type:Individual
Prefix:
First Name:ELYSSA
Middle Name:DAWN
Last Name:BARNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9649 GRETNA GREEN DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-5311
Mailing Address - Country:US
Mailing Address - Phone:813-598-1216
Mailing Address - Fax:
Practice Address - Street 1:9649 GRETNA GREEN DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-5311
Practice Address - Country:US
Practice Address - Phone:813-598-1216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-22
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN240341223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics