MEDICARE: JEFFREY ELLENBERG DMD PA

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	122300000X	Dentist	DN11742	FL

General Provider Information

NPI Number	:	1740389030
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JEFFREY ELLENBERG DMD PA

Provider Business Mailing Address
First Line	:	1430 BELCHER ROAD SOUTH
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33764
Country	:	US
Telephone Number	:	727-531-7751
Fax Number	:	727-532-3006

Provider Business Practice Location Address
First Line	:	1430 BELCHER ROAD SOUTH
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33764
Country	:	US
Telephone Number	:	727-531-7751
Fax Number	:	727-532-3006

Authorized Official
Title or Position	:	PRESIDENT DENTIST OWNER
Name	:	DR. JEFFREY ELLENBERG
Credential	:	DMD
Telephone Number	:	727-531-7751

Provider Enumeration Date	:	09/22/2006
Last Update Date	:	08/22/2020

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