Provider Demographics
NPI:1598963647
Name:ELLIS, JAMES D (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:D
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 1:12100 W CENTER RD
Mailing Address - Street 2:STE 521
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-3969
Mailing Address - Country:US
Mailing Address - Phone:402-333-3343
Mailing Address - Fax:402-333-3344
Practice Address - Street 1:12100 W CENTER RD
Practice Address - Street 2:STE. 521
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-3969
Practice Address - Country:US
Practice Address - Phone:402-333-3343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-10
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA08694122300000X
CO94401223G0001X
NE6920122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice