Provider Demographics
NPI:1114121654
Name:ELLIOTT, WAYDE BRYANT (DMD)
Entity Type:Individual
Prefix:DR
First Name:WAYDE
Middle Name:BRYANT
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 1:575 S COLUMBIA RIVER HWY
Mailing Address - Street 2:
Mailing Address - City:SAINT HELENS
Mailing Address - State:OR
Mailing Address - Zip Code:97051-2835
Mailing Address - Country:US
Mailing Address - Phone:503-397-3326
Mailing Address - Fax:503-397-1150
Practice Address - Street 1:575 S COLUMBIA RIVER HWY
Practice Address - Street 2:
Practice Address - City:SAINT HELENS
Practice Address - State:OR
Practice Address - Zip Code:97051-2835
Practice Address - Country:US
Practice Address - Phone:503-397-3326
Practice Address - Fax:503-397-1150
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD71831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice