Healthcare Provider Details

I. General information

NPI: 1447570403
Provider Name (Legal Business Name): WILLIAM J ELLINGSON D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2010
Last Update Date: 08/21/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 E 11400 S SUITE 2
SANDY UT
84094-6906
US

IV. Provider business mailing address

1030 E 11400 S SUITE 2
SANDY UT
84094-6906
US

V. Phone/Fax

Practice location:
  • Phone: 801-255-2100
  • Fax: 801-619-8669
Mailing address:
  • Phone: 801-255-2100
  • Fax: 801-619-8669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8414288
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number25409
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8414288-9922
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: