Provider Demographics
NPI:1164038030
Name:ELLSON, TAYLOR AUSTIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:TAYLOR
Middle Name:AUSTIN
Last Name:ELLSON
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:PO BOX 1150
Mailing Address - Street 2:
Mailing Address - City:SHADY COVE
Mailing Address - State:OR
Mailing Address - Zip Code:97539-1150
Mailing Address - Country:US
Mailing Address - Phone:541-878-2115
Mailing Address - Fax:
Practice Address - Street 1:21300 HIGHWAY 62
Practice Address - Street 2:
Practice Address - City:SHADY COVE
Practice Address - State:OR
Practice Address - Zip Code:97539-7707
Practice Address - Country:US
Practice Address - Phone:541-878-2115
Practice Address - Fax:541-878-2117
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD113241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice