Basic Information
| Provider Information | |||||||||
| NPI: | 1174834030 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ASANAKI | ||||||||
| FirstName: | ELAINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 W 8TH ST | ||||||||
| Address2: | SUITE 810 | ||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810033038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195624447 | ||||||||
| FaxNumber: | 7195831801 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 W 8TH ST | ||||||||
| Address2: | SUITE 810 | ||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810033038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195624447 | ||||||||
| FaxNumber: | 7195831801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2010 | ||||||||
| LastUpdateDate: | 12/11/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 1223P0221X | DN1856107 | MA | Y | Dental Providers | Dentist | Pediatric Dentistry | 1223P0221X | 010521 | CT | N | Dental Providers | Dentist | Pediatric Dentistry |
ID Information
| ID | Type | State | Issuer | Description | 110089498A | 05 | MA | MEDICAID | 008032579 | 05 | CT | MEDICAID |