Provider Demographics
NPI:1871547166
Name:ELLIOTT, ROBERT W (DDS,PC)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:W
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:DDS,PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1808 S PENNSYLVANIA AVE
Mailing Address - Street 2:STE D
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-1897
Mailing Address - Country:US
Mailing Address - Phone:517-372-5051
Mailing Address - Fax:517-372-5989
Practice Address - Street 1:1808 S PENNSYLVANIA AVE
Practice Address - Street 2:STE D
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-1897
Practice Address - Country:US
Practice Address - Phone:517-372-5051
Practice Address - Fax:517-372-5989
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010118951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice