Healthcare Provider Details

I. General information

NPI: 1497195119
Provider Name (Legal Business Name): JESS T ELLIS DDS, MS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2013
Last Update Date: 06/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11741 BARR RD
ANCHORAGE AK
99516-2164
US

IV. Provider business mailing address

11741 BARR RD
ANCHORAGE AK
99516-2164
US

V. Phone/Fax

Practice location:
  • Phone: 907-272-3636
  • Fax: 907-272-3635
Mailing address:
  • Phone: 907-272-3636
  • Fax: 907-272-3635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number682
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier3072011582976
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name: DR. JESS T ELLIS
Title or Position: PRESIDENT
Credential: DDS, MS
Phone: 907-272-3636