Provider Demographics
NPI:1093040800
Name:ELLIS, SCOTT BRADLEY (DMD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:BRADLEY
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23520 OVERLAND DR STE 134
Mailing Address - Street 2:
Mailing Address - City:DULLES
Mailing Address - State:VA
Mailing Address - Zip Code:20166-2197
Mailing Address - Country:US
Mailing Address - Phone:703-661-3360
Mailing Address - Fax:703-661-3363
Practice Address - Street 1:23520 OVERLAND DR STE 134
Practice Address - Street 2:
Practice Address - City:DULLES
Practice Address - State:VA
Practice Address - Zip Code:20166-2197
Practice Address - Country:US
Practice Address - Phone:703-661-3360
Practice Address - Fax:703-661-3363
Is Sole Proprietor?:No
Enumeration Date:2009-10-13
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401411747122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist