Provider Demographics
NPI:1780604801
Name:ELLIS, FRED RAY JR (DMD)
Entity type:Individual
Prefix:DR
First Name:FRED
Middle Name:RAY
Last Name:ELLIS
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 S. PLEASANT AVE.
Mailing Address - Street 2:#303
Mailing Address - City:SOMERSET
Mailing Address - State:PA
Mailing Address - Zip Code:15501-2188
Mailing Address - Country:US
Mailing Address - Phone:814-445-4636
Mailing Address - Fax:814-445-1018
Practice Address - Street 1:233 S. PLEASANT AVE.
Practice Address - Street 2:#303
Practice Address - City:SOMERSET
Practice Address - State:PA
Practice Address - Zip Code:15501-2188
Practice Address - Country:US
Practice Address - Phone:814-445-4636
Practice Address - Fax:814-445-1018
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADSO22283L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0801431OtherDPA
PADSO22283LOtherDENTAL LICENSE
PADSO22283LOtherDENTAL LICENSE