Provider Demographics
NPI:1740389030
Name:JEFFREY ELLENBERG DMD PA
Entity Type:Organization
Organization Name:JEFFREY ELLENBERG DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:727-531-7751
Mailing Address - Street 1:1430 BELCHER ROAD SOUTH
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33764
Mailing Address - Country:US
Mailing Address - Phone:727-531-7751
Mailing Address - Fax:727-532-3006
Practice Address - Street 1:1430 BELCHER ROAD SOUTH
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33764
Practice Address - Country:US
Practice Address - Phone:727-531-7751
Practice Address - Fax:727-532-3006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN11742122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty