Provider Demographics
NPI:1336216456
Name:ELLIOTT, JAY R (DDS)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:R
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 1:3487 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506
Mailing Address - Country:US
Mailing Address - Phone:951-369-1001
Mailing Address - Fax:951-369-1007
Practice Address - Street 1:3487 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506
Practice Address - Country:US
Practice Address - Phone:951-369-1001
Practice Address - Fax:951-369-1007
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA268411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice