Provider Demographics
NPI:1255424214
Name:ELLIS, DIANA HWEI-ANN JAN (DDS)
Entity type:Individual
Prefix:DR
First Name:DIANA
Middle Name:HWEI-ANN JAN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:DIANA
Other - Middle Name:HWEI-ANN
Other - Last Name:JAN-ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:505 N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1266
Mailing Address - Country:US
Mailing Address - Phone:517-748-5500
Mailing Address - Fax:517-780-9286
Practice Address - Street 1:500 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1223
Practice Address - Country:US
Practice Address - Phone:517-748-5500
Practice Address - Fax:517-780-9286
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDJ0188401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID801057OtherBCBS PROVIDER NUMBER
MI744718389Medicaid
MI88131OtherDELTA DENTAL PROVIDER NUM