Basic Information
| Provider Information | |||||||||
| NPI: | 1497726194 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCRAE | ||||||||
| FirstName: | ELISSA | ||||||||
| MiddleName: | JOY | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 71620 JUANITA DR | ||||||||
| Address2: | |||||||||
| City: | TWENTYNINE PALMS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603671323 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1ST DENTAL BATALLION NDC | ||||||||
| Address2: | |||||||||
| City: | CAMP PENDLETON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920555221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607253213 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 5924-015 | WI | Y | Dental Providers | Dentist | General Practice |
No ID Information.