Provider Demographics
NPI:1750388864
Name:ELLIS, HARVEY S (DDS)
Entity type:Individual
Prefix:DR
First Name:HARVEY
Middle Name:S
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 1:29055 FORD RD
Mailing Address - Street 2:STE A
Mailing Address - City:GARDEN CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48135-2964
Mailing Address - Country:US
Mailing Address - Phone:734-522-3510
Mailing Address - Fax:734-522-3526
Practice Address - Street 1:29055 FORD RD
Practice Address - Street 2:STE A
Practice Address - City:GARDEN CITY
Practice Address - State:MI
Practice Address - Zip Code:48135-2964
Practice Address - Country:US
Practice Address - Phone:734-522-3510
Practice Address - Fax:734-522-3526
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-05
Last Update Date:2007-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010089821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice