Basic Information
| Provider Information | |||||||||
| NPI: | 1467915892 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELEMA | ||||||||
| FirstName: | MARYLUCY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 445 CENTENNIAL AVE | ||||||||
| Address2: | |||||||||
| City: | BUTTE | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597012870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067234075 | ||||||||
| FaxNumber: | 4067233059 | ||||||||
| Practice Location | |||||||||
| Address1: | 445 CENTENNIAL AVE | ||||||||
| Address2: | |||||||||
| City: | BUTTE | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597012870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062340757 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2019 | ||||||||
| LastUpdateDate: | 06/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 1223G0001X | DE61088351 | WA | Y | Dental Providers | Dentist | General Practice |
No ID Information.