Provider Demographics
NPI:1497956742
Name:ELLINGSON, MITCHELL WARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:WARD
Last Name:ELLINGSON
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 1:4025 N FOUNDER CIR
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85396-3686
Mailing Address - Country:US
Mailing Address - Phone:623-377-6185
Mailing Address - Fax:
Practice Address - Street 1:4530 E SHEA BLVD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-6065
Practice Address - Country:US
Practice Address - Phone:602-992-4510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ72291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice