Kerisa Sue Elloway, D.D.S.
Individual provider Active NPI Pediatric Dentistry · Fortuna, CA
NPI 1154452324 · NPPES record last updated Jul 8, 2007
Key facts
- NPI
- 1154452324
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Pediatric Dentistry 1223P0221X
- License
- 47254 (CA)
- Practice address
- 1730 Main St
Suite a
Fortuna, CA 95540-2451 - Phone
- (707) 725-1303
- Fax
- (707) 725-1358
- NPI assigned
- Mar 8, 2007
- Sex
- Female
- Sole proprietor
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 47254 | CA | MD | Pediatric Dentist |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatric Dentistry | 1223P0221X | 47254 | CA | Yes |
Addresses
Primary practice location
1730 Main St
Suite a
Fortuna, CA 95540-2451
Mailing address
1730 Main St Ste a
Fortuna, CA 95540-2451
Phone (707) 725-1303
Other providers in Fortuna, CA
- Tamara Smith Douglass
- Fannette Downie-Allman
- Clare Edwards
- Eel River Valley Surgical Group
- Kelly Ehrhardt
- Courtney Embry
- Gabriel Enriquez
- Dana Louise Estevo
- Katherine Anne Talbert Estlin
- Family Foot Care Specialist Podiatry Center
All providers in Fortuna, CA · Pediatric Dentistry in California
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 8, 2007. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.