Healthcare Provider Details

I. General information

NPI: 1083098636
Provider Name (Legal Business Name): LESLIE ELLINGSON D.D.S., M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2015
Last Update Date: 10/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 N 144TH ST
OMAHA NE
68154-4715
US

IV. Provider business mailing address

320 INGLEWOOD CIR
PAPILLION NE
68133-3366
US

V. Phone/Fax

Practice location:
  • Phone: 402-496-9733
  • Fax:
Mailing address:
  • Phone: 402-719-4858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number7251
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: