Provider Demographics
NPI:1790393213
Name:ELLISON, MATTHEW T (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:T
Last Name:ELLISON
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 1:2828 W AVENUE O4
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93551-3402
Mailing Address - Country:US
Mailing Address - Phone:661-917-4077
Mailing Address - Fax:
Practice Address - Street 1:WOMACK ARMY MEDICAL CENTER 2817 REILLY ROAD
Practice Address - Street 2:
Practice Address - City:FORT LIBERTY
Practice Address - State:NC
Practice Address - Zip Code:28310-0001
Practice Address - Country:US
Practice Address - Phone:910-907-6974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD11258122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist