Provider Demographics
NPI:1568558468
Name:ELLIS, JEREMY W (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:W
Last Name:ELLIS
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 1:965 S 100 W
Mailing Address - Street 2:#102
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-6062
Mailing Address - Country:US
Mailing Address - Phone:435-752-9741
Mailing Address - Fax:435-753-5169
Practice Address - Street 1:965 S 100 W
Practice Address - Street 2:#102
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-6062
Practice Address - Country:US
Practice Address - Phone:435-752-9741
Practice Address - Fax:435-753-5169
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT99-373-92899221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice