Provider Demographics
NPI:1720458359
Name:ELLIS BURKE JARDINE, DMD, PC
Entity Type:Organization
Organization Name:ELLIS BURKE JARDINE, DMD, PC
Other - Org Name:ADVANCED DENTAL SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLIS
Authorized Official - Middle Name:BURKE
Authorized Official - Last Name:JARDINE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:360-253-9792
Mailing Address - Street 1:406 SE 131ST AVE STE 305
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-4014
Mailing Address - Country:US
Mailing Address - Phone:360-253-9792
Mailing Address - Fax:360-604-5266
Practice Address - Street 1:406 SE 131ST AVE STE 305
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-4014
Practice Address - Country:US
Practice Address - Phone:360-253-9792
Practice Address - Fax:360-604-5266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA603398651223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAWA 60339865OtherWA DENTAL LICENSE
FJ4151318OtherDEA