Provider Demographics
NPI:1578903498
Name:ELLETT, WILLIAM BRYAN (LAC)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:BRYAN
Last Name:ELLETT
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10252 E NORTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75238-4408
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10252 E NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75238-4408
Practice Address - Country:US
Practice Address - Phone:214-267-8636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC01439171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist