Provider Demographics
NPI:1083724843
Name:ELLIS, ROBERT LYNN (DDS)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LYNN
Last Name:ELLIS
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 1:243 E FREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-1410
Mailing Address - Country:US
Mailing Address - Phone:208-745-0400
Mailing Address - Fax:208-745-5005
Practice Address - Street 1:143 1/2 E MAIN
Practice Address - Street 2:
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442
Practice Address - Country:US
Practice Address - Phone:208-745-0400
Practice Address - Fax:208-745-5005
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3529122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806083700Medicaid