Provider Demographics
NPI:1659494375
Name:ELLIS, R BENJAMIN (DDS)
Entity Type:Individual
Prefix:
First Name:R
Middle Name:BENJAMIN
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 1:12725 PATRICK HENRY DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-9516
Mailing Address - Country:US
Mailing Address - Phone:757-874-6712
Mailing Address - Fax:757-886-1319
Practice Address - Street 1:12725 PATRICK HENRY DR
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-9516
Practice Address - Country:US
Practice Address - Phone:757-874-6712
Practice Address - Fax:757-886-1319
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04081122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist