Provider Demographics
NPI:1497195119
Name:JESS T ELLIS DDS, MS, INC
Entity Type:Organization
Organization Name:JESS T ELLIS DDS, MS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JESS
Authorized Official - Middle Name:T
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:907-272-3636
Mailing Address - Street 1:11741 BARR RD
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99516-2164
Mailing Address - Country:US
Mailing Address - Phone:907-272-3636
Mailing Address - Fax:907-272-3635
Practice Address - Street 1:11741 BARR RD
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99516-2164
Practice Address - Country:US
Practice Address - Phone:907-272-3636
Practice Address - Fax:907-272-3635
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JESS T ELLIS DDS, MS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-06-26
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK6821223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK3072011582976Medicaid