Provider Demographics
NPI:1407103203
Name:ELLIS, JAMES CLAYTON (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:CLAYTON
Last Name:ELLIS
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 1:1710 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:PROSSER
Mailing Address - State:WA
Mailing Address - Zip Code:99350-1517
Mailing Address - Country:US
Mailing Address - Phone:509-786-1881
Mailing Address - Fax:509-786-7476
Practice Address - Street 1:1710 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:PROSSER
Practice Address - State:WA
Practice Address - Zip Code:99350-1517
Practice Address - Country:US
Practice Address - Phone:509-786-1881
Practice Address - Fax:509-786-7476
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-10
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE 60294430122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist