Provider Demographics
NPI:1669149944
Name:ELLIS, TIMOTHY WAYNE JR (DMD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:WAYNE
Last Name:ELLIS
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3929 W ANGELA DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-3012
Mailing Address - Country:US
Mailing Address - Phone:720-427-4909
Mailing Address - Fax:
Practice Address - Street 1:4955 S PEORIA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-4629
Practice Address - Country:US
Practice Address - Phone:918-895-6568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-25
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD011115122300000X
OK7797122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist