Provider Demographics
NPI:1083714885
Name:ELLSWORTH, RICHARD D (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:D
Last Name:ELLSWORTH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 PROFESSIONAL CT.
Mailing Address - Street 2:STE A
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-5153
Mailing Address - Country:US
Mailing Address - Phone:765-449-2757
Mailing Address - Fax:765-449-2759
Practice Address - Street 1:150 PROFESSIONAL CT.
Practice Address - Street 2:STE A
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-5153
Practice Address - Country:US
Practice Address - Phone:765-449-2757
Practice Address - Fax:765-449-2759
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice