Provider Demographics
NPI:1972711794
Name:ELITE DENTAL GROUP, PA
Entity Type:Organization
Organization Name:ELITE DENTAL GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIE
Authorized Official - Middle Name:HA
Authorized Official - Last Name:LUONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-457-4141
Mailing Address - Street 1:1501 HANDLEY DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112-3328
Mailing Address - Country:US
Mailing Address - Phone:817-451-4141
Mailing Address - Fax:817-457-4142
Practice Address - Street 1:1501 HANDLEY DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76112-3328
Practice Address - Country:US
Practice Address - Phone:817-451-4141
Practice Address - Fax:817-457-4142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX189941223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty