Provider Demographics
NPI:1558569368
Name:ELLIS, HOLLIE BURDT (DDS)
Entity Type:Individual
Prefix:DR
First Name:HOLLIE
Middle Name:BURDT
Last Name:ELLIS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MRS
Other - First Name:HOLLIE
Other - Middle Name:BURDT
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1200 W OLD LIBERTY RD
Mailing Address - Street 2:
Mailing Address - City:SYKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21784-9398
Mailing Address - Country:US
Mailing Address - Phone:410-795-8833
Mailing Address - Fax:410-795-6033
Practice Address - Street 1:1200 W OLD LIBERTY RD
Practice Address - Street 2:
Practice Address - City:SYKESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21784-9398
Practice Address - Country:US
Practice Address - Phone:410-795-8833
Practice Address - Fax:410-795-6033
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD125671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice