Provider Demographics
NPI:1629043690
Name:ELLIS, JAMES SHELTON (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:SHELTON
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 1:2407 S WALDRON RD
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-3736
Mailing Address - Country:US
Mailing Address - Phone:479-484-1011
Mailing Address - Fax:479-484-1205
Practice Address - Street 1:2407 S WALDRON RD
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-3736
Practice Address - Country:US
Practice Address - Phone:479-484-1011
Practice Address - Fax:479-484-1205
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR15521223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR58152Medicare ID - Type Unspecified
ART20403Medicare UPIN