Provider Demographics
NPI:1760774558
Name:ELLSWORTH, BENJAMIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:
Last Name:ELLSWORTH
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 1:505 BACHELOR BUTTON ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89138-6077
Mailing Address - Country:US
Mailing Address - Phone:424-744-7695
Mailing Address - Fax:
Practice Address - Street 1:505 BACHELOR BUTTON ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89138-6077
Practice Address - Country:US
Practice Address - Phone:424-744-7695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-11
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV65061223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics