Provider Demographics
NPI:1083054076
Name:BLATTEL, ELLEN (DDS)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:BLATTEL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:849 JEFFCO BLVD
Mailing Address - Street 2:
Mailing Address - City:ARNOLD
Mailing Address - State:MO
Mailing Address - Zip Code:63010-1409
Mailing Address - Country:US
Mailing Address - Phone:636-321-0135
Mailing Address - Fax:
Practice Address - Street 1:4300 GRAVOIS RD
Practice Address - Street 2:
Practice Address - City:HOUSE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:63051-2304
Practice Address - Country:US
Practice Address - Phone:636-321-0135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-05
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20160111931223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health