Provider Demographics
NPI:1013027937
Name:ELLIS, HOLLY (DDS)
Entity Type:Individual
Prefix:
First Name:HOLLY
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 1:10296 BIG BEND RD STE 207
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63122-6582
Mailing Address - Country:US
Mailing Address - Phone:314-965-1334
Mailing Address - Fax:314-965-0679
Practice Address - Street 1:10296 BIG BEND RD STE 207
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122-6582
Practice Address - Country:US
Practice Address - Phone:314-965-1334
Practice Address - Fax:314-965-0679
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20060211791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice