Provider Demographics
NPI:1619520087
Name:ELLEDGE, IANA (DMD)
Entity Type:Individual
Prefix:
First Name:IANA
Middle Name:
Last Name:ELLEDGE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 S 1ST ST STE 160
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-3048
Mailing Address - Country:US
Mailing Address - Phone:512-653-4009
Mailing Address - Fax:
Practice Address - Street 1:4801 AMARRA DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78735-1845
Practice Address - Country:US
Practice Address - Phone:408-221-9128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-24
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX354301223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist