Provider Demographics
NPI:1982331518
Name:ELLIS, BRADYN REIS (DDS)
Entity Type:Individual
Prefix:
First Name:BRADYN
Middle Name:REIS
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 1:406 E THORN ST
Mailing Address - Street 2:
Mailing Address - City:COLFAX
Mailing Address - State:WA
Mailing Address - Zip Code:99111-1616
Mailing Address - Country:US
Mailing Address - Phone:509-553-9084
Mailing Address - Fax:
Practice Address - Street 1:1055 W FAIRVIEW ST
Practice Address - Street 2:
Practice Address - City:COLFAX
Practice Address - State:WA
Practice Address - Zip Code:99111-5106
Practice Address - Country:US
Practice Address - Phone:509-397-4077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-03
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61316972122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist