Healthcare Provider Details

I. General information

NPI: 1255424214
Provider Name (Legal Business Name): DIANA HWEI-ANN JAN ELLIS D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANA HWEI-ANN JAN-ELLIS D.D.S.

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N JACKSON ST
JACKSON MI
49201-1223
US

IV. Provider business mailing address

505 N JACKSON ST
JACKSON MI
49201-1266
US

V. Phone/Fax

Practice location:
  • Phone: 517-748-5500
  • Fax: 517-780-9286
Mailing address:
  • Phone: 517-748-5500
  • Fax: 517-780-9286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDJ018840
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: