Provider Demographics
NPI:1386164655
Name:BANASIK, ELISABETH ANNA
Entity type:Individual
Prefix:MS
First Name:ELISABETH
Middle Name:ANNA
Last Name:BANASIK
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 1:10 ELEVEN RIVER
Mailing Address - Street 2:
Mailing Address - City:ROCKY RIVER
Mailing Address - State:OH
Mailing Address - Zip Code:44116
Mailing Address - Country:US
Mailing Address - Phone:216-280-6949
Mailing Address - Fax:
Practice Address - Street 1:CASE WESTERN RESERVE SCHOOL OF DENTAL MEDICINE
Practice Address - Street 2:2124 CORNELL ROAD
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106
Practice Address - Country:US
Practice Address - Phone:216-368-8665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-27
Last Update Date:2017-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30024966122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty