=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548119092
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELITE LEGACY COLLECTIVE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2026
-----------------------------------------------------
Last Update Date | 01/27/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9712 BELAIR RD STE 304
-----------------------------------------------------
City | NOTTINGHAM
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21236-1113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-538-2422
-----------------------------------------------------
Fax | 410-538-2944
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9712 BELAIR RD STE 304
-----------------------------------------------------
City | NOTTINGHAM
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21236-1113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-538-2422
-----------------------------------------------------
Fax | 410-538-2944
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DANA TRUESDALE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 804-614-8812
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------