Provider Demographics
NPI:1003682873
Name:ST ELMO DENTAL LLC
Entity Type:Organization
Organization Name:ST ELMO DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAYLOR
Authorized Official - Middle Name:
Authorized Official - Last Name:LAWSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-821-9771
Mailing Address - Street 1:3918 TENNESSEE AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37409-1352
Mailing Address - Country:US
Mailing Address - Phone:423-821-7711
Mailing Address - Fax:
Practice Address - Street 1:3918 TENNESSEE AVE STE 300
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37409-1352
Practice Address - Country:US
Practice Address - Phone:423-821-7711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-01
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental