Provider Demographics
NPI:1700016912
Name:ELLIS, SIMONE (DDS)
Entity Type:Individual
Prefix:
First Name:SIMONE
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 1:8300 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77061-1802
Mailing Address - Country:US
Mailing Address - Phone:713-641-3777
Mailing Address - Fax:
Practice Address - Street 1:6300 WEST LOOP S STE 650
Practice Address - Street 2:
Practice Address - City:BELLAIRE
Practice Address - State:TX
Practice Address - Zip Code:77401-2997
Practice Address - Country:US
Practice Address - Phone:713-663-7960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-22
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX246451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice