MEDICARE: DR. JAY EDWARD ELLIOTT D.D.S

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	122300000X	Dentist	12723	TX

General Provider Information

NPI Number	:	1639502172
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAY EDWARD ELLIOTT D.D.S

Provider Business Mailing Address
First Line	:	4005 BROADWAY ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77087-4703
Country	:	US
Telephone Number	:	713-644-4331
Fax Number	:	713-644-1975

Provider Business Practice Location Address
First Line	:	4005 BROADWAY ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77087-4703
Country	:	US
Telephone Number	:	713-644-4331
Fax Number	:	713-644-1975

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

Provider Enumeration Date	:	08/20/2013
Last Update Date	:	08/20/2013

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