Provider Demographics
NPI:1689856148
Name:ELLINGSON, DAVID JOHN (DDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JOHN
Last Name:ELLINGSON
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 1:3549 E. BROWN RD.
Mailing Address - Street 2:STE 104
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213
Mailing Address - Country:US
Mailing Address - Phone:480-830-2956
Mailing Address - Fax:490-830-3019
Practice Address - Street 1:3549 E BROWN RD
Practice Address - Street 2:STE 104
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-5508
Practice Address - Country:US
Practice Address - Phone:480-830-2956
Practice Address - Fax:480-830-3019
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ97397122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist