Provider Demographics
NPI:1639502172
Name:ELLIOTT, JAY EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:EDWARD
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 1:4005 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77087-4703
Mailing Address - Country:US
Mailing Address - Phone:713-644-4331
Mailing Address - Fax:713-644-1975
Practice Address - Street 1:4005 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77087-4703
Practice Address - Country:US
Practice Address - Phone:713-644-4331
Practice Address - Fax:713-644-1975
Is Sole Proprietor?:No
Enumeration Date:2013-08-20
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12723122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist