Provider Demographics
NPI:1760528905
Name:ELLIOTT II, OLIN ANDREW (DMD)
Entity Type:Individual
Prefix:
First Name:OLIN
Middle Name:ANDREW
Last Name:ELLIOTT II
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:ANDY
Other - Middle Name:
Other - Last Name:ELLIOTT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD PSC
Mailing Address - Street 1:PO BOX 1381
Mailing Address - Street 2:196 KY HWY 3188
Mailing Address - City:MARTIN
Mailing Address - State:KY
Mailing Address - Zip Code:41649
Mailing Address - Country:US
Mailing Address - Phone:606-285-9317
Mailing Address - Fax:606-285-4842
Practice Address - Street 1:196 KY HWY 3188
Practice Address - Street 2:
Practice Address - City:MARTIN
Practice Address - State:KY
Practice Address - Zip Code:41649
Practice Address - Country:US
Practice Address - Phone:606-285-9317
Practice Address - Fax:606-285-4842
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5605122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60056058Medicaid