Healthcare Provider Details

I. General information

NPI: 1124098942
Provider Name (Legal Business Name): SCOTT ELLARD DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5835 OAKLAND DRIVE
PORTAGE MI
49024
US

IV. Provider business mailing address

5835 OAKLAND DRIVE
PORTAGE MI
49024
US

V. Phone/Fax

Practice location:
  • Phone: 269-329-1880
  • Fax: 269-329-1886
Mailing address:
  • Phone: 269-329-1880
  • Fax: 269-329-1886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12873
License Number StateMI

VIII. Authorized Official

Name: DR. SCOTT F ELLARD
Title or Position: OWNER
Credential: DDS
Phone: 269-329-1880