Provider Demographics
NPI:1821107442
Name:DRS ERIN AND RANDY ELLIOTT PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:DRS ERIN AND RANDY ELLIOTT PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:H
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:270-782-0716
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY77171223P0221X
KY72321223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60-001716Medicaid