Provider Demographics
NPI:1053935155
Name:NORONHA, ELIJAH (DDS)
Entity type:Individual
Prefix:DR
First Name:ELIJAH
Middle Name:
Last Name:NORONHA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5716 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48210-3039
Mailing Address - Country:US
Mailing Address - Phone:313-554-3880
Mailing Address - Fax:
Practice Address - Street 1:5716 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48210-3039
Practice Address - Country:US
Practice Address - Phone:313-554-3880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-04
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016005191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice