Provider Demographics
NPI:1538571005
Name:TEASDALE, ELISSA LAUREN (DMD)
Entity type:Individual
Prefix:DR
First Name:ELISSA
Middle Name:LAUREN
Last Name:TEASDALE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 MILLSTREAM LN
Mailing Address - Street 2:
Mailing Address - City:PENACOOK
Mailing Address - State:NH
Mailing Address - Zip Code:03303-1819
Mailing Address - Country:US
Mailing Address - Phone:603-738-1308
Mailing Address - Fax:
Practice Address - Street 1:1000 TANNER FORD BLVD
Practice Address - Street 2:
Practice Address - City:HANAHAN
Practice Address - State:SC
Practice Address - Zip Code:29410-4707
Practice Address - Country:US
Practice Address - Phone:843-818-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-02
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCDGD.8377 GD122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist