MEDICARE: ELLINGSEN -PAXTON DDS PS

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	DE00005607	WA
2	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	60083394	WA
3	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	DE00006352	WA

General Provider Information

NPI Number	:	1558446278
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELLINGSEN -PAXTON DDS PS

Provider Business Mailing Address
First Line	:	12109 E BROADWAY AVE STE B
Second Line	:
City	:	SPOKANE VALLEY
State	:	WA
Zip	:	99206-6133
Country	:	US
Telephone Number	:	509-926-0570
Fax Number	:	509-921-9163

Provider Business Practice Location Address
First Line	:	12109 E BROADWAY AVE STE B
Second Line	:
City	:	SPOKANE VALLEY
State	:	WA
Zip	:	99206-6133
Country	:	US
Telephone Number	:	509-926-0570
Fax Number	:	509-921-9163

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RICHARD C ELLINGSEN
Credential	:	DDS
Telephone Number	:	509-926-0570

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	11/19/2009

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