Provider Demographics
NPI:1356564769
Name:RICH, TERRY ELLSWORTH (DDS)
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:ELLSWORTH
Last Name:RICH
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 1:218 E WILLAMETTE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903
Mailing Address - Country:US
Mailing Address - Phone:719-633-3711
Mailing Address - Fax:719-633-1721
Practice Address - Street 1:218 E WILLAMETTE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903
Practice Address - Country:US
Practice Address - Phone:719-633-3711
Practice Address - Fax:719-633-1721
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCOLOHD1002731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice