Provider Demographics
NPI:1972884328
Name:ELLENBERGER, JAMES DENNIS (D,D,S)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:DENNIS
Last Name:ELLENBERGER
Suffix:
Gender:M
Credentials:D,D,S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6919 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-2839
Mailing Address - Country:US
Mailing Address - Phone:951-684-3049
Mailing Address - Fax:951-686-8302
Practice Address - Street 1:6919 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2839
Practice Address - Country:US
Practice Address - Phone:951-684-3049
Practice Address - Fax:951-686-8302
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-30
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA212461223G0001X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223P0221XDental ProvidersDentistPediatric Dentistry