Provider Demographics
NPI:1396410353
Name:ELLIS-CRENSHAW, IRICE (RDH)
Entity Type:Individual
Prefix:MISS
First Name:IRICE
Middle Name:
Last Name:ELLIS-CRENSHAW
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17344 W 12 MILE RD STE 201
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-6321
Mailing Address - Country:US
Mailing Address - Phone:586-277-8491
Mailing Address - Fax:
Practice Address - Street 1:17344 W 12 MILE RD STE 201
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-6321
Practice Address - Country:US
Practice Address - Phone:586-277-8491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-12
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902019162124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist