Provider Demographics
NPI:1487823191
Name:ELLIS, RANDY KYLE
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:KYLE
Last Name:ELLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77581-5698
Mailing Address - Country:US
Mailing Address - Phone:281-485-6003
Mailing Address - Fax:
Practice Address - Street 1:2015 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77581-5698
Practice Address - Country:US
Practice Address - Phone:281-485-6003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-27
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX154041223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics