Provider Demographics
NPI:1821667635
Name:ELLIS, KELLE LOUISE (DMD)
Entity Type:Individual
Prefix:
First Name:KELLE
Middle Name:LOUISE
Last Name:ELLIS
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 1:403 N COMMERCIAL ST APT 201
Mailing Address - Street 2:
Mailing Address - City:TRINIDAD
Mailing Address - State:CO
Mailing Address - Zip Code:81082-1903
Mailing Address - Country:US
Mailing Address - Phone:615-300-1490
Mailing Address - Fax:
Practice Address - Street 1:TRINIDAD FAMILY DENTAL
Practice Address - Street 2:2124 FREEDOM RD
Practice Address - City:TRINIDAD
Practice Address - State:CO
Practice Address - Zip Code:81082-8108
Practice Address - Country:US
Practice Address - Phone:719-422-5696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-24
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.00205742122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist