Provider Demographics
NPI:1568198299
Name:ELLIOTT, WILLIAM OTTO (DDS)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:OTTO
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21055 PUTTING AVE
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MN
Mailing Address - Zip Code:55033-8744
Mailing Address - Country:US
Mailing Address - Phone:651-285-2797
Mailing Address - Fax:
Practice Address - Street 1:701 HOSPITAL LOOP BLDG 9008
Practice Address - Street 2:
Practice Address - City:FAIRCHILD AFB
Practice Address - State:WA
Practice Address - Zip Code:99011-8704
Practice Address - Country:US
Practice Address - Phone:651-285-2797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-26
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND14756122300000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist