Provider Demographics
NPI:1083169668
Name:ERIC C ELLINGSEN DDS PS
Entity Type:Organization
Organization Name:ERIC C ELLINGSEN DDS PS
Other - Org Name:SMILE SOURCE SPOKANE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:C
Authorized Official - Last Name:ELLINGSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-924-2866
Mailing Address - Street 1:1215 N MCDONALD RD
Mailing Address - Street 2:#203
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99216-1557
Mailing Address - Country:US
Mailing Address - Phone:509-924-2866
Mailing Address - Fax:
Practice Address - Street 1:1215 N MCDONALD RD
Practice Address - Street 2:#203
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-1557
Practice Address - Country:US
Practice Address - Phone:509-924-2866
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601992748261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental