Provider Demographics
NPI:1851040604
Name:AVERSA, ELENA F (DMD)
Entity type:Individual
Prefix:DR
First Name:ELENA
Middle Name:F
Last Name:AVERSA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:269 GORDEN DR
Mailing Address - Street 2:
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-3323
Mailing Address - Country:US
Mailing Address - Phone:201-835-6459
Mailing Address - Fax:
Practice Address - Street 1:2107B COTTMAN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19149-1122
Practice Address - Country:US
Practice Address - Phone:215-235-4060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-21
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCDGD.10176122300000X
390200000X
PADS043906122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program