Provider Demographics
NPI:1588998454
Name:WIEST CORTEZ, ELISA K (DDS)
Entity type:Individual
Prefix:DR
First Name:ELISA
Middle Name:K
Last Name:WIEST CORTEZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:ELISA
Other - Middle Name:K
Other - Last Name:WIEST
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:4920 SOUTH 30TH STREET
Mailing Address - Street 2:SUITE 103
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68107-1656
Mailing Address - Country:US
Mailing Address - Phone:402-734-4110
Mailing Address - Fax:402-991-5642
Practice Address - Street 1:4920 SOUTH 30TH STREET
Practice Address - Street 2:SUITE 103
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68107-1656
Practice Address - Country:US
Practice Address - Phone:402-734-4110
Practice Address - Fax:402-991-5642
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-25
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE6685122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist