Healthcare Provider Details

I. General information

NPI: 1700840717
Provider Name (Legal Business Name): GARY LYNN ELLIS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 CHIPETA WAY
SALT LAKE CITY UT
84108-1221
US

IV. Provider business mailing address

500 CHIPETA WAY
SALT LAKE CITY UT
84108-1221
US

V. Phone/Fax

Practice location:
  • Phone: 801-583-2787
  • Fax: 801-584-5255
Mailing address:
  • Phone: 801-583-2787
  • Fax: 801-584-5255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number5129775-9921
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: