Provider Demographics
NPI:1679689749
Name:ELLISON, JUNE L (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUNE
Middle Name:L
Last Name:ELLISON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 S BROAD ST
Mailing Address - Street 2:DENTAL SUITE
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-1613
Mailing Address - Country:US
Mailing Address - Phone:215-685-6768
Mailing Address - Fax:215-685-6891
Practice Address - Street 1:321 W GIRARD AVE
Practice Address - Street 2:HEALTH CENTER #6
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19123-1531
Practice Address - Country:US
Practice Address - Phone:215-685-3808
Practice Address - Fax:215-685-3848
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS024266L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U82085Medicare UPIN