Provider Demographics
NPI:1588795736
Name:ELLSWORTH, CRAIG C (DDS)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:C
Last Name:ELLSWORTH
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 1:826 N MULLAN RD STE C
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99206-4094
Mailing Address - Country:US
Mailing Address - Phone:509-924-1580
Mailing Address - Fax:509-924-1619
Practice Address - Street 1:826 N MULLAN RD
Practice Address - Street 2:STE C
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-4094
Practice Address - Country:US
Practice Address - Phone:509-924-1580
Practice Address - Fax:509-924-1619
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB382751223G0001X
WADE60390327122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice