Provider Demographics
NPI:1033888201
Name:ELLIS, EMILIE BONOVITCH (RDH)
Entity Type:Individual
Prefix:MRS
First Name:EMILIE
Middle Name:BONOVITCH
Last Name:ELLIS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8801 NESBIT FERRY LN
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23832-2133
Mailing Address - Country:US
Mailing Address - Phone:804-349-8146
Mailing Address - Fax:
Practice Address - Street 1:27 BRIGGS DR STE A
Practice Address - Street 2:
Practice Address - City:MANAKIN SABOT
Practice Address - State:VA
Practice Address - Zip Code:23103-2250
Practice Address - Country:US
Practice Address - Phone:804-784-2386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-10
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0402206328124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist