Provider Demographics
NPI:1568531754
Name:ELLINWOOD, STEVEN PENN (DDS)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:PENN
Last Name:ELLINWOOD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5725 MAPLECREST RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-3838
Mailing Address - Country:US
Mailing Address - Phone:260-492-2640
Mailing Address - Fax:260-486-5512
Practice Address - Street 1:5725 MAPLECREST RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46835-3838
Practice Address - Country:US
Practice Address - Phone:260-492-2640
Practice Address - Fax:260-486-5512
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120086891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice