Provider Demographics
NPI:1760202014
Name:ELITE DENTAL, LLC
Entity type:Organization
Organization Name:ELITE DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:DAIGREPONT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:318-359-0009
Mailing Address - Street 1:705 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROUNDUP
Mailing Address - State:MT
Mailing Address - Zip Code:59072-2423
Mailing Address - Country:US
Mailing Address - Phone:318-359-0009
Mailing Address - Fax:
Practice Address - Street 1:2376 MAIN ST STE 812
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59105-4018
Practice Address - Country:US
Practice Address - Phone:406-656-5200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-11
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty