Provider Demographics
NPI:1518215458
Name:ELLIS, PRESTON CHAD (MS, DDS)
Entity Type:Individual
Prefix:DR
First Name:PRESTON
Middle Name:CHAD
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MS, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3575 N 100 E STE 200
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-6653
Mailing Address - Country:US
Mailing Address - Phone:801-374-0070
Mailing Address - Fax:
Practice Address - Street 1:3575 N 100 E STE 200
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-6653
Practice Address - Country:US
Practice Address - Phone:801-374-0070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-27
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT270828-99231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice