Provider Demographics
NPI:1316390388
Name:ELLIOTT, ALEXA NICOLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALEXA
Middle Name:NICOLE
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 VISTA LA CUESTA
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:92688-1003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3487 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2115
Practice Address - Country:US
Practice Address - Phone:951-369-1001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-14
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100428122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist