Provider Demographics
NPI:1659599116
Name:NIST, ELLEN G (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:G
Last Name:NIST
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3555 CLIFFHANGER WAY
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-6420
Mailing Address - Country:US
Mailing Address - Phone:740-450-3636
Mailing Address - Fax:740-450-8321
Practice Address - Street 1:3555 CLIFFHANGER WAY
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-6420
Practice Address - Country:US
Practice Address - Phone:740-450-3636
Practice Address - Fax:740-450-8321
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH189921223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics