Provider Demographics
NPI:1417192717
Name:ELLIOTT, ELIZABETH ANNE (DDS)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANNE
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ANNE
Other - Last Name:BRYANT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3820 E BRISTOL ST
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-4383
Mailing Address - Country:US
Mailing Address - Phone:574-264-4161
Mailing Address - Fax:
Practice Address - Street 1:3820 E BRISTOL ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-4383
Practice Address - Country:US
Practice Address - Phone:574-264-4161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-16
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009560122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist