Healthcare Provider Details

I. General information

NPI: 1972884328
Provider Name (Legal Business Name): JAMES DENNIS ELLENBERGER D,D,S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2011
Last Update Date: 08/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6919 MAGNOLIA AVE
RIVERSIDE CA
92506-2839
US

IV. Provider business mailing address

6919 MAGNOLIA AVE
RIVERSIDE CA
92506-2839
US

V. Phone/Fax

Practice location:
  • Phone: 951-684-3049
  • Fax: 951-686-8302
Mailing address:
  • Phone: 951-684-3049
  • Fax: 951-686-8302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number21246
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number21246
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: