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General NPI Number Information
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NPI Number | 1003614165
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Entity Type | Individual
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Provider Name | LAYTON PAUL ELLEDGE
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Gender | Male
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Dates
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Enumeration Date | 03/05/2025
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Last Update Date | 07/30/2025
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Provider Practice Location Address
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Address Line | 4605 NW 23RD ST
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City | OKLAHOMA CITY
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State | OK
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Zip | 73127-2128
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Country | US
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Telephone | 405-978-2220
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Fax | 405-978-2221
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Provider Business Mailing Address
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Address Line | 4210 N EDWARDS ST
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City | BOISE
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State | ID
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Zip | 83703-4004
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 8123
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License Number State | OK
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