1760528905 NPI number — OLIN ANDREW ELLIOTT II DMD

Table of content: OLIN ANDREW ELLIOTT II DMD (NPI 1760528905)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760528905 NPI number — OLIN ANDREW ELLIOTT II DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIOTT II
Provider First Name:
OLIN
Provider Middle Name:
ANDREW
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ELLIOTT
Provider Other First Name:
ANDY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DMD PSC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1760528905
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1381
Provider Second Line Business Mailing Address:
196 KY HWY 3188
Provider Business Mailing Address City Name:
MARTIN
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41649
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-285-9317
Provider Business Mailing Address Fax Number:
606-285-4842

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
196 KY HWY 3188
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARTIN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41649
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-285-9317
Provider Business Practice Location Address Fax Number:
606-285-4842
Provider Enumeration Date:
01/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  5605 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223G0001X , with the licence number: 5605 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 60056058 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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