Provider Demographics
NPI:1740661834
Name:RICHARD T. ELLISON, DDS, INC
Entity type:Organization
Organization Name:RICHARD T. ELLISON, DDS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHERRI
Authorized Official - Middle Name:J
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-289-0236
Mailing Address - Street 1:1602 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-4962
Mailing Address - Country:US
Mailing Address - Phone:765-289-0236
Mailing Address - Fax:765-289-8569
Practice Address - Street 1:1602 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-4962
Practice Address - Country:US
Practice Address - Phone:765-289-0236
Practice Address - Fax:765-289-8569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-15
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN65921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty