Provider Demographics
NPI:1700144136
Name:CRYSTAL ELLIS DDS, LLC.
Entity Type:Organization
Organization Name:CRYSTAL ELLIS DDS, LLC.
Other - Org Name:THE SMILE SUITE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:240-565-8159
Mailing Address - Street 1:8455 COLESVILLE RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-3315
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8455 COLESVILLE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-3315
Practice Address - Country:US
Practice Address - Phone:240-565-8159
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-23
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD142201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty