Provider Demographics
NPI:1740490515
Name:ELLIS, PAUL JOSEPH (DDS)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:JOSEPH
Last Name:ELLIS
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 1:8699 GULL RD
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49083-9647
Mailing Address - Country:US
Mailing Address - Phone:269-629-9087
Mailing Address - Fax:269-629-7070
Practice Address - Street 1:8699 GULL RD
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:MI
Practice Address - Zip Code:49083-9647
Practice Address - Country:US
Practice Address - Phone:269-629-9087
Practice Address - Fax:269-629-7070
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI124820122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist