Provider Demographics
NPI:1396944526
Name:ELLIS, EDA (DDS)
Entity type:Individual
Prefix:MS
First Name:EDA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 CENTRAL PARK S
Mailing Address - Street 2:SUITE 7A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-1628
Mailing Address - Country:US
Mailing Address - Phone:212-753-1119
Mailing Address - Fax:212-753-1121
Practice Address - Street 1:30 CENTRAL PARK S
Practice Address - Street 2:SUITE 7A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-1628
Practice Address - Country:US
Practice Address - Phone:212-753-1119
Practice Address - Fax:212-753-1121
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-17
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0444891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice