Healthcare Provider Details

I. General information

NPI: 1538822374
Provider Name (Legal Business Name): ELKRIDGE DENTAL SOUTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2021
Last Update Date: 10/19/2021
Certification Date: 10/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 S HWY 89
JACKSON WY
83001-8514
US

IV. Provider business mailing address

PO BOX 1190
JACKSON WY
83001-1190
US

V. Phone/Fax

Practice location:
  • Phone: 307-733-4122
  • Fax:
Mailing address:
  • Phone: 307-733-2555
  • 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: NATHAN TANNER
Title or Position: PRESIDENT
Credential:
Phone: 503-866-8454