Healthcare Provider Details

I. General information

NPI: 1285166017
Provider Name (Legal Business Name): ALLISON LAWRENCE ELLIS D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2017
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6858 OLD DOMINION DR SUITE 100
MC LEAN VA
22101-3899
US

IV. Provider business mailing address

32 TERRACE AVE
RIVERSIDE CT
06878-2124
US

V. Phone/Fax

Practice location:
  • Phone: 703-356-8781
  • Fax:
Mailing address:
  • Phone: 703-969-4425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number13003
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number050449-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: