Provider Demographics
NPI:1265644116
Name:ELLWOOD, RICHARD JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:JOHN
Last Name:ELLWOOD
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 1:222 MERRICK AVE
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-3143
Mailing Address - Country:US
Mailing Address - Phone:516-379-1222
Mailing Address - Fax:
Practice Address - Street 1:222 MERRICK AVE
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-3143
Practice Address - Country:US
Practice Address - Phone:516-379-4444
Practice Address - Fax:516-867-7196
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031915-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00425461Medicaid