Provider Demographics
NPI:1104697838
Name:ELEVATE PEDIATRIC DENTISTRY LLC
Entity type:Organization
Organization Name:ELEVATE PEDIATRIC DENTISTRY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GAGE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-636-2824
Mailing Address - Street 1:344 NANDINA LOOP
Mailing Address - Street 2:
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36532-7909
Mailing Address - Country:US
Mailing Address - Phone:801-636-2824
Mailing Address - Fax:
Practice Address - Street 1:25265 HIGHWAY 181 STE 105
Practice Address - Street 2:
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-6077
Practice Address - Country:US
Practice Address - Phone:801-636-2824
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-11
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty