Healthcare Provider Details

I. General information

NPI: 1356076152
Provider Name (Legal Business Name): ELITE DENTAL CARE JACKSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2022
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 N STAR DR
JACKSON TN
38305-6647
US

IV. Provider business mailing address

2066 US HIGHWAY 45 BYP S
TRENTON TN
38382-3507
US

V. Phone/Fax

Practice location:
  • Phone: 731-664-9556
  • Fax:
Mailing address:
  • Phone: 731-855-1053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TOM LANNOM
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 731-855-1053