Provider Demographics
NPI:1114026572
Name:ELLENBERG, JEFFREY (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:
Last Name:ELLENBERG
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 1:1430 BELCHER ROAD SOUTH
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33764
Mailing Address - Country:US
Mailing Address - Phone:727-531-7751
Mailing Address - Fax:727-532-3006
Practice Address - Street 1:1430 BELCHER ROAD SOUTH
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33764
Practice Address - Country:US
Practice Address - Phone:727-531-7751
Practice Address - Fax:727-532-3006
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN11742122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist