Provider Demographics
NPI:1477238483
Name:ELLICKSON, LUKE (DDS)
Entity Type:Individual
Prefix:
First Name:LUKE
Middle Name:
Last Name:ELLICKSON
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 1:6115 SATURN DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53718-3129
Mailing Address - Country:US
Mailing Address - Phone:417-569-6575
Mailing Address - Fax:
Practice Address - Street 1:440 SCIENCE DR STE 100
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-1064
Practice Address - Country:US
Practice Address - Phone:608-308-2950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60011911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice