Provider Demographics
NPI:1184859357
Name:ELLMAN, ALAN GARY (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:GARY
Last Name:ELLMAN
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 1:770 MIDDLE COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLE ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:11953-2555
Mailing Address - Country:US
Mailing Address - Phone:631-924-7997
Mailing Address - Fax:631-924-7953
Practice Address - Street 1:770 MIDDLE COUNTRY RD
Practice Address - Street 2:
Practice Address - City:MIDDLE ISLAND
Practice Address - State:NY
Practice Address - Zip Code:11953-2555
Practice Address - Country:US
Practice Address - Phone:631-924-7997
Practice Address - Fax:631-924-7953
Is Sole Proprietor?:No
Enumeration Date:2009-05-18
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0296491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00412533Medicaid