Provider Demographics
NPI:1700840717
Name:ELLIS, GARY LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:LYNN
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 1:500 CHIPETA WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1221
Mailing Address - Country:US
Mailing Address - Phone:801-583-2787
Mailing Address - Fax:801-584-5255
Practice Address - Street 1:500 CHIPETA WAY
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1221
Practice Address - Country:US
Practice Address - Phone:801-583-2787
Practice Address - Fax:801-584-5255
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5129775-99211223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT5129775-9921OtherDENTAL LICENSE