Provider Demographics
NPI:1902297542
Name:ELISHA MAYES, DDS, PC
Entity Type:Organization
Organization Name:ELISHA MAYES, DDS, PC
Other - Org Name:ELI MAYES DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANTAY
Authorized Official - Middle Name:SABIN
Authorized Official - Last Name:MAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-229-0004
Mailing Address - Street 1:1502 N PINE ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-3543
Mailing Address - Country:US
Mailing Address - Phone:541-963-8585
Mailing Address - Fax:541-963-6633
Practice Address - Street 1:1502 N PINE ST
Practice Address - Street 2:SUITE 2
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-3543
Practice Address - Country:US
Practice Address - Phone:541-963-8585
Practice Address - Fax:541-963-6633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-17
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR9190122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty