Provider Demographics
NPI:1922205715
Name:JARDINE, ELLIS BURKE (DMD)
Entity Type:Individual
Prefix:DR
First Name:ELLIS
Middle Name:BURKE
Last Name:JARDINE
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 1:3542 NE FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607-6904
Mailing Address - Country:US
Mailing Address - Phone:480-862-3185
Mailing Address - Fax:
Practice Address - Street 1:406C SE 131ST AVENUE
Practice Address - Street 2:SUITE 305
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-4003
Practice Address - Country:US
Practice Address - Phone:360-253-9792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ72401223G0001X
TX279171223P0700X
WADE 603398651223P0700X
TN94411223P0700X
WADE603398651223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223G0001XDental ProvidersDentistGeneral Practice
No1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FJ4151318OtherDEA