Provider Demographics
NPI:1942437033
Name:NORDGREN, ELLEN DIANE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:DIANE
Last Name:NORDGREN
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 1:314 PICKENS DR N
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27530-9097
Mailing Address - Country:US
Mailing Address - Phone:507-363-6157
Mailing Address - Fax:
Practice Address - Street 1:2720 GRAVES DR
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-4512
Practice Address - Country:US
Practice Address - Phone:919-778-0098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12705122300000X
NC9263122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist