Provider Demographics
NPI:1164509832
Name:ELDER, JACK A (DDS)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:A
Last Name:ELDER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:172 EAST D STREET
Mailing Address - Street 2:
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510-0954
Mailing Address - Country:US
Mailing Address - Phone:707-745-3820
Mailing Address - Fax:707-746-5196
Practice Address - Street 1:172 EAST D STREET
Practice Address - Street 2:
Practice Address - City:BENICIA
Practice Address - State:CA
Practice Address - Zip Code:94510
Practice Address - Country:US
Practice Address - Phone:707-745-3820
Practice Address - Fax:707-746-5196
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55157122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist