Provider Demographics
NPI:1780993840
Name:THEODIS ELZIE, D.D.S., P.C.
Entity type:Organization
Organization Name:THEODIS ELZIE, D.D.S., P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THEODIS
Authorized Official - Middle Name:
Authorized Official - Last Name:ELZIE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-801-1641
Mailing Address - Street 1:705 WINDY HILL RD SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-1854
Mailing Address - Country:US
Mailing Address - Phone:770-808-1641
Mailing Address - Fax:770-801-0587
Practice Address - Street 1:705 WINDY HILL RD SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-1854
Practice Address - Country:US
Practice Address - Phone:770-808-1641
Practice Address - Fax:770-801-0587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-06
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN010679122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty