Provider Demographics
NPI:1356828347
Name:ELLIS, TRENT PARKER (DMD)
Entity Type:Individual
Prefix:
First Name:TRENT
Middle Name:PARKER
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9434 COPPERWAY
Mailing Address - Street 2:
Mailing Address - City:CONVERSE
Mailing Address - State:TX
Mailing Address - Zip Code:78109-2063
Mailing Address - Country:US
Mailing Address - Phone:801-859-7315
Mailing Address - Fax:
Practice Address - Street 1:9040A JACKSON AVENUE
Practice Address - Street 2:
Practice Address - City:JOINT BASE LEWIS MCCHORD
Practice Address - State:WA
Practice Address - Zip Code:98431-7719
Practice Address - Country:US
Practice Address - Phone:253-968-0174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-23
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA614045261223S0112X
KY10101122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist