Provider Demographics
NPI:1245292721
Name:ELLIS, ANDRE (DDS)
Entity type:Individual
Prefix:DR
First Name:ANDRE
Middle Name:
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 1:4013 GATEWAY DR
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-5917
Mailing Address - Country:US
Mailing Address - Phone:817-858-6333
Mailing Address - Fax:817-868-0068
Practice Address - Street 1:4013 GATEWAY DR
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-5917
Practice Address - Country:US
Practice Address - Phone:817-858-6333
Practice Address - Fax:817-868-0068
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX163401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice