Provider Demographics
NPI:1477526069
Name:ELLIS, KEVIN JOHN (DMD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JOHN
Last Name:ELLIS
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 1:1360 LITTLE NECK RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-4740
Mailing Address - Country:US
Mailing Address - Phone:757-631-0553
Mailing Address - Fax:
Practice Address - Street 1:205 34TH ST
Practice Address - Street 2:SUITE 112
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-2836
Practice Address - Country:US
Practice Address - Phone:757-428-5491
Practice Address - Fax:757-428-7663
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA71761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice