Provider Demographics
NPI:1962554824
Name:PENAFIEL, ELISE GAYOSO (DDS)
Entity type:Individual
Prefix:DR
First Name:ELISE
Middle Name:GAYOSO
Last Name:PENAFIEL
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 1:1173 GUMBOTTOM RD
Mailing Address - Street 2:
Mailing Address - City:CROWNSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21032-1517
Mailing Address - Country:US
Mailing Address - Phone:410-987-0785
Mailing Address - Fax:
Practice Address - Street 1:7425 BALTIMORE ANNAPOLIS BLVD
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-3507
Practice Address - Country:US
Practice Address - Phone:410-760-5120
Practice Address - Fax:410-760-9470
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD127451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice