Provider Demographics
NPI:1700974953
Name:ELLENBECKER, RICHARD JOSEPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:JOSEPH
Last Name:ELLENBECKER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5201 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-5004
Mailing Address - Country:US
Mailing Address - Phone:605-339-2200
Mailing Address - Fax:605-334-5530
Practice Address - Street 1:5201 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-5004
Practice Address - Country:US
Practice Address - Phone:605-339-2200
Practice Address - Fax:605-334-5530
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM3131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0937011Medicaid
SD7803400Medicaid
MN926228Medicaid