Provider Demographics
NPI:1386649630
Name:ELLINGER, HARLEY A JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:HARLEY
Middle Name:A
Last Name:ELLINGER
Suffix:JR
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 1:3325 SPRINGBANK LN
Mailing Address - Street 2:STE 140
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-3364
Mailing Address - Country:US
Mailing Address - Phone:704-544-2224
Mailing Address - Fax:704-544-2259
Practice Address - Street 1:3325 SPRINGBANK LN
Practice Address - Street 2:STE 140
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-3364
Practice Address - Country:US
Practice Address - Phone:704-544-2224
Practice Address - Fax:704-544-2259
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36701223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3670OtherDENTAL LICENSE
2425188Medicare ID - Type Unspecified
NC3670OtherDENTAL LICENSE