MEDICARE: DR. LEAH DARLA ELKHOURY DMD

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	29256	FL

General Provider Information

NPI Number	:	1821834078
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LEAH DARLA ELKHOURY DMD

Provider Business Mailing Address
First Line	:	1900 OLEVIA ST APT 308
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-3483
Country	:	US
Telephone Number	:	781-752-8274
Fax Number	:

Provider Business Practice Location Address
First Line	:	4220 VALLEY RIDGE BLVD STE 101
Second Line	:
City	:	PONTE VEDRA
State	:	FL
Zip	:	32081-5173
Country	:	US
Telephone Number	:	904-354-0339
Fax Number	:

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

Provider Enumeration Date	:	07/08/2024
Last Update Date	:	07/08/2024

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