Provider Demographics
NPI:1427582147
Name:DR. EDA ELLIS DENTAL PC
Entity Type:Organization
Organization Name:DR. EDA ELLIS DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-753-1119
Mailing Address - Street 1:30 CENTRAL PARK S
Mailing Address - Street 2:SUITE 7A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-1628
Mailing Address - Country:US
Mailing Address - Phone:212-753-1119
Mailing Address - Fax:212-753-1139
Practice Address - Street 1:30 CENTRAL PARK S
Practice Address - Street 2:SUITE 7A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-1628
Practice Address - Country:US
Practice Address - Phone:212-753-1119
Practice Address - Fax:212-753-1139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-19
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty