Provider Demographics
NPI:1326051285
Name:RANDAL W ELLIS DMD PLLC
Entity Type:Organization
Organization Name:RANDAL W ELLIS DMD PLLC
Other - Org Name:ELLIS DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDAL
Authorized Official - Middle Name:W
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:360-592-1100
Mailing Address - Street 1:PO BOX 608
Mailing Address - Street 2:
Mailing Address - City:DEMING
Mailing Address - State:WA
Mailing Address - Zip Code:98244
Mailing Address - Country:US
Mailing Address - Phone:360-592-1100
Mailing Address - Fax:360-592-5067
Practice Address - Street 1:3739 MT BAKER HWY
Practice Address - Street 2:
Practice Address - City:EVERSON
Practice Address - State:WA
Practice Address - Zip Code:98247-9406
Practice Address - Country:US
Practice Address - Phone:360-592-1100
Practice Address - Fax:360-592-5067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000084701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty