Healthcare Provider Details

I. General information

NPI: 1598021016
Provider Name (Legal Business Name): JONATHAN CLINTON ELMORE D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 01/31/2021
Certification Date: 01/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12711 NARCOOSSEE RD BLDG B, #100
ORLANDO FL
32832-4355
US

IV. Provider business mailing address

10524 MOSS PARK RD STE 204-616
ORLANDO FL
32832-5898
US

V. Phone/Fax

Practice location:
  • Phone: 407-627-1235
  • Fax:
Mailing address:
  • Phone: 678-480-9808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number24213
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: