Provider Demographics
NPI:1609128065
Name:ELLISON, JOHN GERALD (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:GERALD
Last Name:ELLISON
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 1:1658 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-4842
Mailing Address - Country:US
Mailing Address - Phone:812-882-6098
Mailing Address - Fax:
Practice Address - Street 1:1658 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-4842
Practice Address - Country:US
Practice Address - Phone:812-882-6098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12006937A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice