Provider Demographics
NPI:1326339888
Name:THOMAS A. ELLIOTT, D.D.S.
Entity Type:Organization
Organization Name:THOMAS A. ELLIOTT, D.D.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:573-446-1775
Mailing Address - Street 1:2718 FORUM BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-5451
Mailing Address - Country:US
Mailing Address - Phone:573-446-1775
Mailing Address - Fax:
Practice Address - Street 1:2718 FORUM BLVD.
Practice Address - Street 2:SUITE 1
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203
Practice Address - Country:US
Practice Address - Phone:573-446-1775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-02
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO12697122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO12697OtherDENTIST