Provider Demographics
NPI:1831419811
Name:ELLISS, JOSHUA LEVI (DMD)
Entity type:Individual
Prefix:DR
First Name:JOSHUA
Middle Name:LEVI
Last Name:ELLISS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:JOSHUA
Other - Middle Name:LEVI
Other - Last Name:ELLISS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD LLC
Mailing Address - Street 1:3015 HILLRISE DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4703
Mailing Address - Country:US
Mailing Address - Phone:575-522-0454
Mailing Address - Fax:575-522-3472
Practice Address - Street 1:3015 HILLRISE DR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4703
Practice Address - Country:US
Practice Address - Phone:575-522-0454
Practice Address - Fax:575-522-3472
Is Sole Proprietor?:No
Enumeration Date:2010-06-02
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25432122300000X
NMDD3482122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM29879876Medicaid