MEDICARE: STEVEN PENN ELLINWOOD DDS

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	1223G0001X	General Practice Dentistry	12008689	IN

General Provider Information

NPI Number	:	1568531754
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEVEN PENN ELLINWOOD DDS

Provider Business Mailing Address
First Line	:	5725 MAPLECREST RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46835-3838
Country	:	US
Telephone Number	:	260-492-2640
Fax Number	:	260-486-5512

Provider Business Practice Location Address
First Line	:	5725 MAPLECREST RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46835-3838
Country	:	US
Telephone Number	:	260-492-2640
Fax Number	:	260-486-5512

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

Provider Enumeration Date	:	11/06/2006
Last Update Date	:	07/08/2007

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