Provider Demographics
NPI:1689847683
Name:ERIC ELLINGSEN DDS, PS
Entity Type:Organization
Organization Name:ERIC ELLINGSEN DDS, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:C
Authorized Official - Last Name:ELLINGSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:509-924-2866
Mailing Address - Street 1:1215 N MCDONALD RD STE 203
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99216-1557
Mailing Address - Country:US
Mailing Address - Phone:509-924-2866
Mailing Address - Fax:509-924-8311
Practice Address - Street 1:1215 N MCDONALD RD STE 203
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-1557
Practice Address - Country:US
Practice Address - Phone:509-924-2866
Practice Address - Fax:509-924-8311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-10
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE797031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty