Provider Demographics
NPI:1407134927
Name:DOMMER, ELISABETH L (DDS)
Entity type:Individual
Prefix:DR
First Name:ELISABETH
Middle Name:L
Last Name:DOMMER
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 1:2701 NICOLLET AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-1631
Mailing Address - Country:US
Mailing Address - Phone:612-874-7674
Mailing Address - Fax:612-874-1117
Practice Address - Street 1:2701 NICOLLET AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-1631
Practice Address - Country:US
Practice Address - Phone:612-874-7674
Practice Address - Fax:612-874-1117
Is Sole Proprietor?:No
Enumeration Date:2011-08-01
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12939122300000X
WI6683-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist