Provider Demographics
NPI:1073516365
Name:ELLIS DDS PC, JERRY R
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:R
Last Name:ELLIS DDS PC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:TX
Mailing Address - Zip Code:76065-2946
Mailing Address - Country:US
Mailing Address - Phone:972-775-2345
Mailing Address - Fax:972-775-4729
Practice Address - Street 1:404 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:TX
Practice Address - Zip Code:76065-2946
Practice Address - Country:US
Practice Address - Phone:972-775-2345
Practice Address - Fax:972-775-4729
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX137421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice