Provider Demographics
NPI:1902398068
Name:ELLIS, JORDAN MICHAEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:MICHAEL
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1118 DOUGLAS ST
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-2219
Mailing Address - Country:US
Mailing Address - Phone:217-799-9533
Mailing Address - Fax:
Practice Address - Street 1:1900 EAST MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-6183
Practice Address - Country:US
Practice Address - Phone:217-554-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-05
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019031635122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist