Provider Demographics
NPI:1497841134
Name:ELLISON, JON CHARLES (DDS)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:CHARLES
Last Name:ELLISON
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 1:1939 ERRINGER RD
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-3524
Mailing Address - Country:US
Mailing Address - Phone:805-527-6100
Mailing Address - Fax:805-527-0038
Practice Address - Street 1:1939 ERRINGER RD
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-3524
Practice Address - Country:US
Practice Address - Phone:805-527-6100
Practice Address - Fax:805-527-0038
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice