Provider Demographics
NPI:1891835310
Name:ELLIS, FRED E (DPD DENTURIST OF PRO)
Entity Type:Individual
Prefix:MR
First Name:FRED
Middle Name:E
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DPD DENTURIST OF PRO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1822 BLACK LAKE BLVD SW
Mailing Address - Street 2:SUITE 101
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98512
Mailing Address - Country:US
Mailing Address - Phone:360-709-9909
Mailing Address - Fax:360-709-9915
Practice Address - Street 1:1822 BLACK LAKE BLVD SW
Practice Address - Street 2:SUITE 101
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98512
Practice Address - Country:US
Practice Address - Phone:360-709-9909
Practice Address - Fax:360-709-9915
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN00000358122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5046370Medicaid