Provider Demographics
NPI:1588272140
Name:FOSSATTI GONCALVES, ELIANE (DDS)
Entity type:Individual
Prefix:DR
First Name:ELIANE
Middle Name:
Last Name:FOSSATTI GONCALVES
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 1:802 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-6309
Mailing Address - Country:US
Mailing Address - Phone:217-679-2896
Mailing Address - Fax:
Practice Address - Street 1:802 N 9TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-6309
Practice Address - Country:US
Practice Address - Phone:217-679-2896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-20
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190328151223G0001X
MO20210201281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice