Provider Demographics
NPI:1891433553
Name:ELLIS, KAYLA MARIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KAYLA
Middle Name:MARIE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:753 CRESTVIEW DR N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55119-3280
Mailing Address - Country:US
Mailing Address - Phone:952-715-1293
Mailing Address - Fax:
Practice Address - Street 1:7150 VALLEY CREEK PLZ STE 230
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55125-2271
Practice Address - Country:US
Practice Address - Phone:651-217-8296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-23
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MND14773122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program