Provider Demographics
NPI:1750348199
Name:ELLIS, EDWARD III (DDS MS)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:ELLIS
Suffix:III
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8210 FLOYD CURL DR
Mailing Address - Street 2:MC 8124
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3923
Mailing Address - Country:US
Mailing Address - Phone:210-450-3131
Mailing Address - Fax:210-450-2219
Practice Address - Street 1:7703 FLOYD CURL DR
Practice Address - Street 2:MC 7908
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3901
Practice Address - Country:US
Practice Address - Phone:210-567-3465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX157871223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111043901Medicaid
TX111043901Medicaid
TX864404Medicare UPIN