Provider Demographics
NPI:1578695839
Name:ELLIS, BRENT L (DDS)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:L
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 1:2163 HWY 54 EAST
Mailing Address - Street 2:
Mailing Address - City:LINTON
Mailing Address - State:IN
Mailing Address - Zip Code:47441
Mailing Address - Country:US
Mailing Address - Phone:812-847-8601
Mailing Address - Fax:812-847-8750
Practice Address - Street 1:2163HWY 54 EAST SUBURBAN PLAZA
Practice Address - Street 2:SUITE C
Practice Address - City:LINTON
Practice Address - State:IN
Practice Address - Zip Code:47441
Practice Address - Country:US
Practice Address - Phone:812-847-8601
Practice Address - Fax:812-847-8750
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120080901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice