Provider Demographics
NPI:1215535695
Name:ELLINGSEN HENNEBERG PLLC
Entity Type:Organization
Organization Name:ELLINGSEN HENNEBERG PLLC
Other - Org Name:SMILE SOURCE SPOKANE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:C
Authorized Official - Last Name:ELLINGSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:509-924-2866
Mailing Address - Street 1:1215 N MCDONALD RD STE 203
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99216-1557
Mailing Address - Country:US
Mailing Address - Phone:509-924-2866
Mailing Address - Fax:509-924-8311
Practice Address - Street 1:2607 S SOUTHEAST BLVD STE B210
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99223-7614
Practice Address - Country:US
Practice Address - Phone:509-924-2866
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELLINGSEN HENNEBERG PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-10-16
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental