Provider Demographics
NPI:1003703406
Name:ELLIS, KAYLA (DDS)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 SE BELMONT ST APT 501
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-4686
Mailing Address - Country:US
Mailing Address - Phone:248-595-3635
Mailing Address - Fax:
Practice Address - Street 1:1710 NE 122ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-1939
Practice Address - Country:US
Practice Address - Phone:503-295-2120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-19
Last Update Date:2025-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD121941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice