Provider Demographics
NPI:1568162238
Name:BRENT L ELLIS DDS PC
Entity Type:Organization
Organization Name:BRENT L ELLIS DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:L
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:812-847-8601
Mailing Address - Street 1:PO BOX 635
Mailing Address - Street 2:
Mailing Address - City:LINTON
Mailing Address - State:IN
Mailing Address - Zip Code:47441-0635
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:290 A ST SE
Practice Address - Street 2:
Practice Address - City:LINTON
Practice Address - State:IN
Practice Address - Zip Code:47441-1844
Practice Address - Country:US
Practice Address - Phone:812-847-8601
Practice Address - Fax:812-847-8750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty