MEDICARE: MRS. HEIDI ELLIS RDH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	DH00004498	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1285853788
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. HEIDI ELLIS RDH

Provider Business Mailing Address
First Line	:	1822 BLACK LAKE BLVD SW STE 101
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98512-5628
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1822 BLACK LAKE BLVD SW STE 101
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98512-5628
Country	:	US
Telephone Number	:	360-709-9909
Fax Number	:	360-709-9915

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/24/2007
Last Update Date	:	07/08/2007

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