Provider Demographics
NPI:1952830689
Name:ELLIS, CHASE DANIEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHASE
Middle Name:DANIEL
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1019 GHANER RD STE 100
Mailing Address - Street 2:
Mailing Address - City:PORT MATILDA
Mailing Address - State:PA
Mailing Address - Zip Code:16870-7236
Mailing Address - Country:US
Mailing Address - Phone:814-238-7120
Mailing Address - Fax:814-238-2981
Practice Address - Street 1:1019 GHANER RD STE 100
Practice Address - Street 2:
Practice Address - City:PORT MATILDA
Practice Address - State:PA
Practice Address - Zip Code:16870-7236
Practice Address - Country:US
Practice Address - Phone:814-238-7120
Practice Address - Fax:814-238-2981
Is Sole Proprietor?:No
Enumeration Date:2017-06-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-0418981223G0001X
390200000X
PADS0418981223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1035609330001Medicaid