Provider Demographics
NPI:1871582437
Name:ELLIOTT, THOMAS A (DDS)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2718 FORUM BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-5451
Mailing Address - Country:US
Mailing Address - Phone:573-446-1775
Mailing Address - Fax:573-446-1802
Practice Address - Street 1:2718 FORUM BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-5451
Practice Address - Country:US
Practice Address - Phone:573-446-1775
Practice Address - Fax:573-446-1802
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO126971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice