Provider Demographics
NPI:1245745413
Name:ELAM, TRILBY JADE (RDH)
Entity Type:Individual
Prefix:
First Name:TRILBY
Middle Name:JADE
Last Name:ELAM
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:MS
Other - First Name:TRILBY
Other - Middle Name:JADE
Other - Last Name:ELAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:1543 LA MESA CIR
Mailing Address - Street 2:
Mailing Address - City:RANGELY
Mailing Address - State:CO
Mailing Address - Zip Code:81648-3811
Mailing Address - Country:US
Mailing Address - Phone:970-629-9198
Mailing Address - Fax:
Practice Address - Street 1:606 N 1700 W
Practice Address - Street 2:
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-8200
Practice Address - Country:US
Practice Address - Phone:435-789-1748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-09
Last Update Date:2017-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6230136-9920124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist