Healthcare Provider Details

I. General information

NPI: 1366771925
Provider Name (Legal Business Name): H. ELLWOOD ERNST, DDS, MS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2009
Last Update Date: 12/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 PROFESSIONAL PARK DR
VICTORIA TX
77904-2351
US

IV. Provider business mailing address

108 PROFESSIONAL PARK DR
VICTORIA TX
77904-2351
US

V. Phone/Fax

Practice location:
  • Phone: 361-573-7464
  • Fax: 361-573-0282
Mailing address:
  • Phone: 361-573-7464
  • Fax: 361-573-0282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number8030
License Number StateTX

VIII. Authorized Official

Name: DR. HUGO ELLWOOD ERNST
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 361-573-7464