Provider Demographics
NPI:1073611547
Name:ELLIS II, RICHARD LEROY (DMD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:LEROY
Last Name:ELLIS II
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 1:5 S 700 E
Mailing Address - Street 2:SUITE B-30
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1135
Mailing Address - Country:US
Mailing Address - Phone:801-355-3263
Mailing Address - Fax:801-534-0769
Practice Address - Street 1:5 S 700 E
Practice Address - Street 2:SUITE B-30
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1135
Practice Address - Country:US
Practice Address - Phone:801-355-3263
Practice Address - Fax:801-534-0769
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14084499221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice