Provider Demographics
NPI:1609392034
Name:DEVINNEY, ELLIOT JAMES (DMD)
Entity type:Individual
Prefix:DR
First Name:ELLIOT
Middle Name:JAMES
Last Name:DEVINNEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 CASSELL DR APT 204
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-1606
Mailing Address - Country:US
Mailing Address - Phone:724-316-9563
Mailing Address - Fax:
Practice Address - Street 1:USA DENTAL ACTIVITY, ATTN: MCDS NA B
Practice Address - Street 2:BLDG 6837 NORMANDY DRIVE
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310-7302
Practice Address - Country:US
Practice Address - Phone:910-643-2196
Practice Address - Fax:910-396-7017
Is Sole Proprietor?:No
Enumeration Date:2017-08-17
Last Update Date:2017-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS041295122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADS041295OtherDENTAL LICENSE