Provider Demographics
NPI:1003891201
Name:ELLIS, HEIDI SUSAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:HEIDI
Middle Name:SUSAN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:SUSAN
Other - Last Name:BOREK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:NAVAL POSTGRADUATE SCHOOL
Mailing Address - Street 2:8901 WISCONSIN AVE
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20889-5602
Mailing Address - Country:US
Mailing Address - Phone:301-295-0145
Mailing Address - Fax:
Practice Address - Street 1:NAVAL POSTGRADUATE SCHOOL
Practice Address - Street 2:8901 WISCONSIN AVE
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20889-5602
Practice Address - Country:US
Practice Address - Phone:301-295-0145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010187151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice