Provider Demographics
NPI:1710003231
Name:RUDOLPH JARVIS, ELLEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:
Last Name:RUDOLPH JARVIS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 SYCAMORE CT. SUITE 1-C
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47203
Mailing Address - Country:US
Mailing Address - Phone:812-379-9211
Mailing Address - Fax:
Practice Address - Street 1:3200 SYCAMORE CT. SUITE 1-C
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47203
Practice Address - Country:US
Practice Address - Phone:812-379-9211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010901A122300000X, 1223G0001X
ALD-0006947-C1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist