Provider Demographics
NPI:1437276300
Name:ELLIS, JOHN BOCKHOFF (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:BOCKHOFF
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 1:2901 S FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-4032
Mailing Address - Country:US
Mailing Address - Phone:863-682-8001
Mailing Address - Fax:863-682-4943
Practice Address - Street 1:2901 S FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-4032
Practice Address - Country:US
Practice Address - Phone:863-682-8001
Practice Address - Fax:863-682-4943
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL81511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice