Provider Demographics
NPI:1255565065
Name:ELLIS, STEVEN L (LD)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:L
Last Name:ELLIS
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 SACO AVE
Mailing Address - Street 2:
Mailing Address - City:OLD ORCHARD BEACH
Mailing Address - State:ME
Mailing Address - Zip Code:04064-1600
Mailing Address - Country:US
Mailing Address - Phone:207-934-5411
Mailing Address - Fax:
Practice Address - Street 1:155 SACO AVE
Practice Address - Street 2:
Practice Address - City:OLD ORCHARD BEACH
Practice Address - State:ME
Practice Address - Zip Code:04064-1600
Practice Address - Country:US
Practice Address - Phone:207-934-5411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-07
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME5005122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME431742900OtherMAINE CARE