Provider Demographics
NPI:1609021021
Name:ELLIS, ERIC (DDS PC)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DDS PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 FAIRMONT PKWY
Mailing Address - Street 2:SUITE 204
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77504-3335
Mailing Address - Country:US
Mailing Address - Phone:281-991-1361
Mailing Address - Fax:281-991-9190
Practice Address - Street 1:4600 FAIRMONT PKWY
Practice Address - Street 2:SUITE 204
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77504-3335
Practice Address - Country:US
Practice Address - Phone:281-991-1361
Practice Address - Fax:281-991-9190
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-26
Last Update Date:2008-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX181751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice