Provider Demographics
NPI:1417087719
Name:ELLIS, JEFFREY MARK (DDS, MS,CNS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:MARK
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DDS, MS,CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3237 ROUTE 112
Mailing Address - Street 2:BLDG 6
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-1424
Mailing Address - Country:US
Mailing Address - Phone:631-698-6934
Mailing Address - Fax:631-698-5361
Practice Address - Street 1:3237 ROUTE 112
Practice Address - Street 2:BLDG 6
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-1424
Practice Address - Country:US
Practice Address - Phone:631-698-6934
Practice Address - Fax:631-698-5361
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0395511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice