Provider Demographics
NPI:1629291653
Name:ELLIS, JOE M (DDS)
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:M
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 1:2525 BAY AREA BLVD
Mailing Address - Street 2:SUITE 170
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77058-1558
Mailing Address - Country:US
Mailing Address - Phone:281-488-0387
Mailing Address - Fax:281-488-8350
Practice Address - Street 1:2525 BAY AREA BLVD
Practice Address - Street 2:SUITE 170
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77058-1558
Practice Address - Country:US
Practice Address - Phone:281-488-0387
Practice Address - Fax:281-488-8350
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX83451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice