Provider Demographics
NPI:1093872582
Name:ELLIS, SEAN FRANK (DDS)
Entity Type:Individual
Prefix:DR
First Name:SEAN
Middle Name:FRANK
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 1:1212 EAST 12TH STREET
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-3910
Mailing Address - Country:US
Mailing Address - Phone:307-265-8505
Mailing Address - Fax:307-265-2005
Practice Address - Street 1:1212 EAST 12TH STREET
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-3910
Practice Address - Country:US
Practice Address - Phone:307-265-8505
Practice Address - Fax:307-265-2005
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY825122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist