1821107442 NPI number — DRS ERIN AND RANDY ELLIOTT PEDIATRIC DENTISTRY

Table of content: (NPI 1821107442)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821107442 NPI number — DRS ERIN AND RANDY ELLIOTT PEDIATRIC DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DRS ERIN AND RANDY ELLIOTT PEDIATRIC DENTISTRY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821107442
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 CALLAWAY COURT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOWLING GREEN
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-782-0716
Provider Business Mailing Address Fax Number:
270-746-9603

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 CALLAWAY COURT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOWLING GREEN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-782-0716
Provider Business Practice Location Address Fax Number:
270-746-9603
Provider Enumeration Date:
08/29/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ELLIOTT
Authorized Official First Name:
RANDY
Authorized Official Middle Name:
H
Authorized Official Title or Position:
DOCTOR OWNER
Authorized Official Telephone Number:
270-782-0716

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  7717 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223P0221X , with the licence number: 7232 , 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: 60-001716 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".