Provider Demographics
NPI:1093569550
Name:ELLIOTT, JORDAN KANE (DMD)
Entity Type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:KANE
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 STUART ST UNIT 20D
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-5670
Mailing Address - Country:US
Mailing Address - Phone:617-470-5696
Mailing Address - Fax:
Practice Address - Street 1:146 HIGH ST UNIT 1
Practice Address - Street 2:
Practice Address - City:IPSWICH
Practice Address - State:MA
Practice Address - Zip Code:01938-1212
Practice Address - Country:US
Practice Address - Phone:978-276-9990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-12
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program