Provider Demographics
NPI:1912409657
Name:MACKALL, ELIZABETH MARIE
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARIE
Last Name:MACKALL
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 1:8955 WOOD ROAD
Mailing Address - Street 2:BUILDING 1, ROOM 4405
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20889
Mailing Address - Country:US
Mailing Address - Phone:301-295-0404
Mailing Address - Fax:
Practice Address - Street 1:8955 WOOD ROAD
Practice Address - Street 2:BUILDING 1, ROOM 4405
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20889
Practice Address - Country:US
Practice Address - Phone:301-295-0404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-07
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN23937122300000X, 1223P0106X
171000000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No122300000XDental ProvidersDentist
No1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
No171000000XOther Service ProvidersMilitary Health Care Provider