Basic Information
| Provider Information | |||||||||
| NPI: | 1285231456 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIOTT | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | ELIAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 412 W WEBSTER RD | ||||||||
| Address2: | |||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480733384 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2487945141 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 132 COLE RD | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481624104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342427120 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2020 | ||||||||
| LastUpdateDate: | 10/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 2901600723 | MI | Y | Dental Providers | Dentist | General Practice |
No ID Information.