MEDICARE: DR. KENNETH ELROD DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DN15645	FL

General Provider Information

NPI Number	:	1245386622
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH ELROD DDS

Provider Business Mailing Address
First Line	:	9000 GOLFSIDE DRIVE
Second Line	:	SUITE B
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-7793
Country	:	US
Telephone Number	:	904-367-1722
Fax Number	:	904-367-1739

Provider Business Practice Location Address
First Line	:	1605 110 COUNTY ROAD 220
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32003-4909
Country	:	US
Telephone Number	:	904-215-3533
Fax Number	:	904-264-8783

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/26/2007
Last Update Date	:	11/04/2010

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