Provider Demographics
NPI:1407138837
Name:ELLISON, ROBERT P
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:P
Last Name:ELLISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 PROFESSIONAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:IN
Mailing Address - Zip Code:46774-1850
Mailing Address - Country:US
Mailing Address - Phone:260-493-2113
Mailing Address - Fax:260-493-1896
Practice Address - Street 1:615 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:IN
Practice Address - Zip Code:46774-1850
Practice Address - Country:US
Practice Address - Phone:260-493-2113
Practice Address - Fax:260-493-1896
Is Sole Proprietor?:No
Enumeration Date:2011-09-12
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ININ6593122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist