Provider Demographics
NPI:1083098636
Name:ELLINGSON, LESLIE (DDS, MS)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:ELLINGSON
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 INGLEWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:PAPILLION
Mailing Address - State:NE
Mailing Address - Zip Code:68133-3366
Mailing Address - Country:US
Mailing Address - Phone:402-719-4858
Mailing Address - Fax:
Practice Address - Street 1:1710 N 144TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-4715
Practice Address - Country:US
Practice Address - Phone:402-496-9733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-14
Last Update Date:2019-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE72511223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics