=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194256115
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELISE ODOM R.D.A
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2017
-----------------------------------------------------
Last Update Date | 03/22/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2701 S 77 SUNSHINESTRIP
-----------------------------------------------------
City | HARLINGEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78550-8318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-430-9355
-----------------------------------------------------
Fax | 956-430-9373
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 105 DICKEY ST
-----------------------------------------------------
City | FORT POLK
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71459-3546
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-430-9355
-----------------------------------------------------
Fax | 956-430-9373
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 126800000X
-----------------------------------------------------
Taxonomy Name | Dental Assistant
-----------------------------------------------------
License Number | 35682
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------