Healthcare Provider Details

I. General information

NPI: 1831558907
Provider Name (Legal Business Name): ELLIS JARDINE, DMD, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2016
Last Update Date: 02/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 NW 1ST ST STE 120
BATTLE GROUND WA
98604-4540
US

IV. Provider business mailing address

1401 NW 1ST ST STE 120
BATTLE GROUND WA
98604-4540
US

V. Phone/Fax

Practice location:
  • Phone: 360-666-5700
  • Fax: 360-666-5701
Mailing address:
  • Phone: 360-666-5700
  • Fax: 360-666-5701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDE 60339865
License Number StateWA

VIII. Authorized Official

Name: DR. ELLIS BURKE JARDINE
Title or Position: OWNER
Credential: DMD
Phone: 480-862-3185