Provider Demographics
NPI:1124630462
Name:ELITE PRACTICE MANAGEMENT
Entity type:Organization
Organization Name:ELITE PRACTICE MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:AVANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-314-3585
Mailing Address - Street 1:7185 CRAPE MYRTLE DR
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-1971
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7185 CRAPE MYRTLE DR
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-1971
Practice Address - Country:US
Practice Address - Phone:662-314-3585
Practice Address - Fax:662-346-5438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty