Provider Demographics
NPI:1477114551
Name:DACE, ELLEN H (DMD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:H
Last Name:DACE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 N CLARK ST APT 1501
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-5885
Mailing Address - Country:US
Mailing Address - Phone:708-828-3737
Mailing Address - Fax:
Practice Address - Street 1:5342 S ARCHER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-4949
Practice Address - Country:US
Practice Address - Phone:773-284-2645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-27
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0322001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice