Provider Demographics
NPI:1043662778
Name:ELLSWORTH, JESSE (DMD)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:ELLSWORTH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1018 GARRISON RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-5155
Mailing Address - Country:US
Mailing Address - Phone:801-598-2774
Mailing Address - Fax:
Practice Address - Street 1:126 E DIVISION RD
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-6906
Practice Address - Country:US
Practice Address - Phone:865-481-0008
Practice Address - Fax:865-481-0695
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-06
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS10287122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist