Provider Demographics
NPI:1508243775
Name:ELLSWORTH, ALYSSA (DDS)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2258 W 35TH AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80211-2908
Mailing Address - Country:US
Mailing Address - Phone:314-809-9609
Mailing Address - Fax:
Practice Address - Street 1:4150 DARLEY AVE STE 3
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80305-6537
Practice Address - Country:US
Practice Address - Phone:303-499-0013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-27
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CO002027761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program