Provider Demographics
NPI:1356619084
Name:ELLSWORTH, REBECCA ANN (RDH, COM)
Entity type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:ANN
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:RDH, COM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 W MAPLE ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-1899
Mailing Address - Country:US
Mailing Address - Phone:269-343-7811
Mailing Address - Fax:
Practice Address - Street 1:1011 W MAPLE ST
Practice Address - Street 2:SUITE 300
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-1899
Practice Address - Country:US
Practice Address - Phone:269-343-7811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902005366124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist