Provider Demographics
NPI:1003314535
Name:ELLSWORTH, EVAN BALE (DMD)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:BALE
Last Name:ELLSWORTH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6127 S RAINBOW BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118-3256
Mailing Address - Country:US
Mailing Address - Phone:702-793-2182
Mailing Address - Fax:
Practice Address - Street 1:2660 WINDMILL PKWY
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-3385
Practice Address - Country:US
Practice Address - Phone:702-990-2960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-30
Last Update Date:2019-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7010122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist