Healthcare Provider Details

I. General information

NPI: 1417953431
Provider Name (Legal Business Name): JAMES W ELLIS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 07/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 33RD ST SUITE A
OGDEN UT
84403-1378
US

IV. Provider business mailing address

1220 33RD ST SUITE C
OGDEN UT
84403-1378
US

V. Phone/Fax

Practice location:
  • Phone: 801-621-1835
  • Fax: 801-621-1848
Mailing address:
  • Phone: 801-394-4519
  • Fax: 801-394-4551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5664249-9921
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: