Provider Demographics
NPI:1356076152
Name:ELITE DENTAL CARE JACKSON
Entity Type:Organization
Organization Name:ELITE DENTAL CARE JACKSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:LANNOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-855-1053
Mailing Address - Street 1:2066 US HIGHWAY 45 BYP S
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:TN
Mailing Address - Zip Code:38382-3507
Mailing Address - Country:US
Mailing Address - Phone:731-855-1053
Mailing Address - Fax:
Practice Address - Street 1:47 N STAR DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-6647
Practice Address - Country:US
Practice Address - Phone:731-664-9556
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-18
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental