Provider Demographics
NPI:1316057789
Name:ELLIOTT, MICHAEL ROBERT (DDS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROBERT
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:R
Other - Last Name:ELLIOTT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1615 SPRUCE
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:OK
Mailing Address - Zip Code:78533-2305
Mailing Address - Country:US
Mailing Address - Phone:580-255-5752
Mailing Address - Fax:580-255-5752
Practice Address - Street 1:1615 SPRUCE
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:OK
Practice Address - Zip Code:78533-2305
Practice Address - Country:US
Practice Address - Phone:580-255-5752
Practice Address - Fax:580-255-5752
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3383122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist