Provider Demographics
NPI:1457092926
Name:KATHLEEN ELLSWORTH DDS PC
Entity Type:Organization
Organization Name:KATHLEEN ELLSWORTH DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-642-3500
Mailing Address - Street 1:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:SARANAC
Mailing Address - State:MI
Mailing Address - Zip Code:48881-0070
Mailing Address - Country:US
Mailing Address - Phone:616-642-3500
Mailing Address - Fax:
Practice Address - Street 1:60 N BRIDGE ST
Practice Address - Street 2:
Practice Address - City:SARANAC
Practice Address - State:MI
Practice Address - Zip Code:48881-5109
Practice Address - Country:US
Practice Address - Phone:616-642-3500
Practice Address - Fax:616-642-3600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-06
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental