Provider Demographics
NPI:1568710820
Name:ELLIS, ANDREW W (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:W
Last Name:ELLIS
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 1:151 BODIN CIR
Mailing Address - Street 2:
Mailing Address - City:TRAVIS AFB
Mailing Address - State:CA
Mailing Address - Zip Code:94535-1801
Mailing Address - Country:US
Mailing Address - Phone:707-423-5373
Mailing Address - Fax:
Practice Address - Street 1:101 BODIN CIR
Practice Address - Street 2:
Practice Address - City:TRAVIS AFB
Practice Address - State:CA
Practice Address - Zip Code:94535-1809
Practice Address - Country:US
Practice Address - Phone:707-423-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-16
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002041461223G0001X
390200000X
CA605271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program