Provider Demographics
NPI:1740304542
Name:ELLIS, JACQUELINE DENISE (DMD)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:DENISE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1607 PRESIDENTIAL WAY
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33179-6437
Mailing Address - Country:US
Mailing Address - Phone:305-757-7763
Mailing Address - Fax:
Practice Address - Street 1:5535 NW 7TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33127-1401
Practice Address - Country:US
Practice Address - Phone:305-759-1145
Practice Address - Fax:305-759-1145
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN0011584122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist