Provider Demographics
NPI:1154689636
Name:ELLIS, RANDAL W (DMD PLLC)
Entity Type:Individual
Prefix:
First Name:RANDAL
Middle Name:W
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DMD PLLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 608
Mailing Address - Street 2:
Mailing Address - City:DEMING
Mailing Address - State:WA
Mailing Address - Zip Code:98244-0608
Mailing Address - Country:US
Mailing Address - Phone:360-592-1100
Mailing Address - Fax:360-592-5067
Practice Address - Street 1:3739 MT BAKER HWY
Practice Address - Street 2:
Practice Address - City:EVERSON
Practice Address - State:WA
Practice Address - Zip Code:98247-9406
Practice Address - Country:US
Practice Address - Phone:360-592-1100
Practice Address - Fax:360-592-5067
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-02
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA000084701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice