Healthcare Provider Details

I. General information

NPI: 1376547364
Provider Name (Legal Business Name): JEFF D. ELLARD D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

541 SHADOWS LN STE B
BATON ROUGE LA
70806-6531
US

IV. Provider business mailing address

541 SHADOWS LN STE B
BATON ROUGE LA
70806-6531
US

V. Phone/Fax

Practice location:
  • Phone: 225-924-2010
  • Fax: 225-926-5872
Mailing address:
  • Phone: 225-924-2010
  • Fax: 225-926-5872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number3507
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: