Provider Demographics
NPI:1568664365
Name:ELLICSON, MARK E (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:E
Last Name:ELLICSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33725 N SCOTTSDALE RD
Mailing Address - Street 2:STE101
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85262-1560
Mailing Address - Country:US
Mailing Address - Phone:480-515-5215
Mailing Address - Fax:
Practice Address - Street 1:33725 N SCOTTSDALE RD
Practice Address - Street 2:STE101
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85262-1560
Practice Address - Country:US
Practice Address - Phone:480-515-5215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ45131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice