Provider Demographics
NPI:1700070331
Name:ELLIS ORTHODONTICS, LLC
Entity Type:Organization
Organization Name:ELLIS ORTHODONTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:219-322-7645
Mailing Address - Street 1:275 US HIGHWAY 30
Mailing Address - Street 2:SUITE 260
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-1776
Mailing Address - Country:US
Mailing Address - Phone:219-322-7645
Mailing Address - Fax:
Practice Address - Street 1:275 US HIGHWAY 30
Practice Address - Street 2:SUITE 260
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-1776
Practice Address - Country:US
Practice Address - Phone:219-322-7645
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009958A1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty