Provider Demographics
NPI:1538124342
Name:ELLIS, CHRISTINE PORTER (DDS)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:PORTER
Last Name:ELLIS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:LYNN
Other - Last Name:PORTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:PO BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-5347
Mailing Address - Country:US
Mailing Address - Phone:214-645-3999
Mailing Address - Fax:214-648-2918
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-7201
Practice Address - Country:US
Practice Address - Phone:214-645-3999
Practice Address - Fax:214-648-2918
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX183071223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164228201Medicaid
TX164228201Medicaid
TX8B5238Medicare ID - Type Unspecified