Provider Demographics
NPI:1417087099
Name:ELLEN, STEVEN ARTHUR (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:ARTHUR
Last Name:ELLEN
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:PO BOX 290370
Mailing Address - Street 2:RM 160
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33329-0370
Mailing Address - Country:US
Mailing Address - Phone:954-262-4346
Mailing Address - Fax:954-262-2269
Practice Address - Street 1:1750 NE 167TH ST
Practice Address - Street 2:RM 160
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-3017
Practice Address - Country:US
Practice Address - Phone:954-262-1795
Practice Address - Fax:203-586-2701
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT48021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTU62645Medicare UPIN