Provider Demographics
NPI:1194256115
Name:ODOM, ELISE (RDA)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:ODOM
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 DICKEY ST
Mailing Address - Street 2:
Mailing Address - City:FORT POLK
Mailing Address - State:LA
Mailing Address - Zip Code:71459-3546
Mailing Address - Country:US
Mailing Address - Phone:956-430-9355
Mailing Address - Fax:956-430-9373
Practice Address - Street 1:2701 S 77 SUNSHINESTRIP
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-8318
Practice Address - Country:US
Practice Address - Phone:956-430-9355
Practice Address - Fax:956-430-9373
Is Sole Proprietor?:No
Enumeration Date:2017-03-22
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35682126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant