Provider Demographics
NPI:1629642079
Name:PERELLIS, ETHAN HARRISON (DMD)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:HARRISON
Last Name:PERELLIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9451 WESTPORT RD STE 109
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-2295
Mailing Address - Country:US
Mailing Address - Phone:502-412-5900
Mailing Address - Fax:
Practice Address - Street 1:9451 WESTPORT RD STE 109
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-2295
Practice Address - Country:US
Practice Address - Phone:502-412-5900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-19
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY105821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty