Healthcare Provider Details

I. General information

NPI: 1356828347
Provider Name (Legal Business Name): TRENT PARKER ELLIS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2018
Last Update Date: 09/06/2023
Certification Date: 09/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040A JACKSON AVENUE
JOINT BASE LEWIS MCCHORD WA
98431-7719
US

IV. Provider business mailing address

9434 COPPERWAY
CONVERSE TX
78109-2063
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-0174
  • Fax:
Mailing address:
  • Phone: 801-859-7315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number61404526
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number10101
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: