Provider Demographics
NPI:1811473804
Name:NEW TEETH LEAGUE CITY, PLLC
Entity type:Organization
Organization Name:NEW TEETH LEAGUE CITY, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:832-338-5396
Mailing Address - Street 1:2750 W MAIN ST STE D
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-1830
Mailing Address - Country:US
Mailing Address - Phone:281-554-9090
Mailing Address - Fax:281-554-6394
Practice Address - Street 1:2750 W MAIN ST STE D
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-1830
Practice Address - Country:US
Practice Address - Phone:281-554-9090
Practice Address - Fax:281-554-6394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12723122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty