Provider Demographics
NPI:1982304267
Name:JERRY R ELLIS DDS PC
Entity Type:Organization
Organization Name:JERRY R ELLIS DDS PC
Other - Org Name:JERRY R ELLIS DDS PC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:R
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-775-2345
Mailing Address - Street 1:404 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:TX
Mailing Address - Zip Code:76065-2946
Mailing Address - Country:US
Mailing Address - Phone:972-775-2345
Mailing Address - Fax:
Practice Address - Street 1:404 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:TX
Practice Address - Zip Code:76065-2946
Practice Address - Country:US
Practice Address - Phone:972-775-2345
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-06
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental