Provider Demographics
NPI:1992694822
Name:ELLINGSON, JARED M (DMD)
Entity type:Individual
Prefix:DR
First Name:JARED
Middle Name:M
Last Name:ELLINGSON
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 1:2710 COUNTY ROAD MN
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53527-9514
Mailing Address - Country:US
Mailing Address - Phone:815-262-5332
Mailing Address - Fax:
Practice Address - Street 1:787 N MAIN ST
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:WI
Practice Address - Zip Code:53575-1030
Practice Address - Country:US
Practice Address - Phone:618-819-6688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-03
Last Update Date:2025-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6001882-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist