Provider Demographics
NPI:1225167182
Name:ELLIS, VIRGINIA HERIN (DDS)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:HERIN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:VIRGINIA
Other - Middle Name:HERIN
Other - Last Name:LUK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:405 SUTTON CIRCLE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94506
Mailing Address - Country:US
Mailing Address - Phone:925-648-7442
Mailing Address - Fax:925-648-7442
Practice Address - Street 1:1855 SAN MIGUEL DRIVE
Practice Address - Street 2:SUITE #31
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-5214
Practice Address - Country:US
Practice Address - Phone:925-935-2700
Practice Address - Fax:925-935-0268
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS48825122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist