Provider Demographics
NPI:1558446278
Name:ELLINGSEN -PAXTON DDS PS
Entity Type:Organization
Organization Name:ELLINGSEN -PAXTON DDS PS
Other - Org Name:ELLINGSEN PAXTON JOHNSON ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:C
Authorized Official - Last Name:ELLINGSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:509-926-0570
Mailing Address - Street 1:12109 E BROADWAY AVE STE B
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99206-6133
Mailing Address - Country:US
Mailing Address - Phone:509-926-0570
Mailing Address - Fax:509-921-9163
Practice Address - Street 1:12109 E BROADWAY AVE STE B
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-6133
Practice Address - Country:US
Practice Address - Phone:509-926-0570
Practice Address - Fax:509-921-9163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000063521223X0400X
WADE000056071223X0400X
WA600833941223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty