Provider Demographics
NPI:1750527826
Name:JAMES W ELLIS DDS PC
Entity type:Organization
Organization Name:JAMES W ELLIS DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:W
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-394-4519
Mailing Address - Street 1:1220 33RD ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-1378
Mailing Address - Country:US
Mailing Address - Phone:801-394-4519
Mailing Address - Fax:801-394-4551
Practice Address - Street 1:1220 33RD ST
Practice Address - Street 2:SUITE C
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-1378
Practice Address - Country:US
Practice Address - Phone:801-394-4519
Practice Address - Fax:801-394-4551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-19
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT56642491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT044625126002Medicaid