Provider Demographics
NPI:1154452324
Name:ELLOWAY, KERISA SUE (DDS)
Entity Type:Individual
Prefix:
First Name:KERISA
Middle Name:SUE
Last Name:ELLOWAY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:FORTUNA
Mailing Address - State:CA
Mailing Address - Zip Code:95540-2451
Mailing Address - Country:US
Mailing Address - Phone:707-725-1303
Mailing Address - Fax:707-725-1358
Practice Address - Street 1:1730 MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-2451
Practice Address - Country:US
Practice Address - Phone:707-725-1303
Practice Address - Fax:707-725-1358
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA472541223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry