Provider Demographics
NPI:1598832982
Name:ELLIS, GREGORY (DDS, MSCD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DDS, MSCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 N LOOP 336 W
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-3500
Mailing Address - Country:US
Mailing Address - Phone:936-756-1676
Mailing Address - Fax:936-756-1675
Practice Address - Street 1:2040 N LOOP 336 W
Practice Address - Street 2:SUITE 300
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-3500
Practice Address - Country:US
Practice Address - Phone:936-756-1676
Practice Address - Fax:936-756-1675
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX206221223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics