Provider Demographics
NPI:1245386622
Name:ELROD, KENNETH (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:ELROD
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 1:9000 GOLFSIDE DRIVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-7793
Mailing Address - Country:US
Mailing Address - Phone:904-367-1722
Mailing Address - Fax:904-367-1739
Practice Address - Street 1:1605 110 COUNTY ROAD 220
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32003-4909
Practice Address - Country:US
Practice Address - Phone:904-215-3533
Practice Address - Fax:904-264-8783
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN156451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice