Healthcare Provider Details

I. General information

NPI: 1336216456
Provider Name (Legal Business Name): JAY R ELLIOTT DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3487 CENTRAL AVE
RIVERSIDE CA
92506
US

IV. Provider business mailing address

3487 CENTRAL AVE
RIVERSIDE CA
92506
US

V. Phone/Fax

Practice location:
  • Phone: 951-369-1001
  • Fax: 951-369-1007
Mailing address:
  • Phone: 951-369-1001
  • Fax: 951-369-1007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number26841
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: