Provider Demographics
NPI:1447570403
Name:ELLINGSON, WILLIAM JOHN (DMD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:JOHN
Last Name:ELLINGSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2141 E CAMINO WAY
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD HEIGHTS
Mailing Address - State:UT
Mailing Address - Zip Code:84121-4958
Mailing Address - Country:US
Mailing Address - Phone:903-707-3921
Mailing Address - Fax:
Practice Address - Street 1:850 E 9400 S
Practice Address - Street 2:#100
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-3632
Practice Address - Country:US
Practice Address - Phone:801-255-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-01
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX254091223G0001X
UT8414288-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice