Provider Demographics
NPI:1023550233
Name:ELLIS FAMILY DENTISTRY
Entity Type:Organization
Organization Name:ELLIS FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:HUNTER
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:804-458-6733
Mailing Address - Street 1:3416 WOODLAWN ST
Mailing Address - Street 2:
Mailing Address - City:HOPEWELL
Mailing Address - State:VA
Mailing Address - Zip Code:23860-4738
Mailing Address - Country:US
Mailing Address - Phone:804-458-6733
Mailing Address - Fax:
Practice Address - Street 1:3416 WOODLAWN ST
Practice Address - Street 2:
Practice Address - City:HOPEWELL
Practice Address - State:VA
Practice Address - Zip Code:23860-4738
Practice Address - Country:US
Practice Address - Phone:804-458-6733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRAL VIRGINIA DENTAL CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-11-07
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty