Provider Demographics
NPI:1821182106
Name:ELLIS, GREGORY SEAN (DDS)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:SEAN
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 1:7621 OAKMONT BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-4206
Mailing Address - Country:US
Mailing Address - Phone:817-370-7776
Mailing Address - Fax:817-370-8860
Practice Address - Street 1:7621 OAKMONT BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4206
Practice Address - Country:US
Practice Address - Phone:817-370-7776
Practice Address - Fax:817-370-8860
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX187651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice