Provider Demographics
NPI:1417953431
Name:ELLIS, JAMES W (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:W
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 1:1220 33RD ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-1378
Mailing Address - Country:US
Mailing Address - Phone:801-394-4519
Mailing Address - Fax:801-394-4551
Practice Address - Street 1:1220 33RD ST
Practice Address - Street 2:SUITE A
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-1378
Practice Address - Country:US
Practice Address - Phone:801-621-1835
Practice Address - Fax:801-621-1848
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5664249-9921122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT01638969OtherUNITED CONCORDIA PROV. #