Provider Demographics
NPI:1659480275
Name:ELLIOTT, RANDALL HARLEY (DMD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:HARLEY
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 CALLAWAY COURT
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103
Mailing Address - Country:US
Mailing Address - Phone:270-782-0716
Mailing Address - Fax:270-746-9603
Practice Address - Street 1:120 CALLAWAY COURT
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103
Practice Address - Country:US
Practice Address - Phone:270-782-0716
Practice Address - Fax:270-746-9603
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY77171223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry