Provider Demographics
NPI:1427026095
Name:ELLIS, RANDALL WILLIAM (DDS)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:WILLIAM
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 1:201 W 8TH ST
Mailing Address - Street 2:SUITE 810
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3038
Mailing Address - Country:US
Mailing Address - Phone:719-562-4447
Mailing Address - Fax:719-583-1801
Practice Address - Street 1:2859 E FOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-2312
Practice Address - Country:US
Practice Address - Phone:719-442-0071
Practice Address - Fax:719-473-5303
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN-84751223G0001X
IDD42601223G0001X
OK47831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM41506367Medicaid
KS200371660AMedicaid
CO04880323Medicaid