Provider Demographics
NPI:1407878697
Name:ELLENWOOD, DREW SAMUEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:DREW
Middle Name:SAMUEL
Last Name:ELLENWOOD
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 1:520 S 14TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72901-4608
Mailing Address - Country:US
Mailing Address - Phone:479-782-3005
Mailing Address - Fax:479-494-7490
Practice Address - Street 1:520 S 14TH ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-4608
Practice Address - Country:US
Practice Address - Phone:479-782-3005
Practice Address - Fax:479-494-7490
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2781122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist