Basic Information
| Provider Information | |||||||||
| NPI: | 1750311684 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELIASSEN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 812 10TH ST | ||||||||
| Address2: | |||||||||
| City: | PORT ROYAL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299352422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435217733 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 719 OKATIE HWY # 170 | ||||||||
| Address2: | |||||||||
| City: | OKATIE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299093963 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8439877400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 03/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 8167 | SC | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | ZX8167 | 05 | SC | MEDICAID |