Healthcare Provider Details

I. General information

NPI: 1588795736
Provider Name (Legal Business Name): CRAIG C. ELLSWORTH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 02/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 N MULLAN RD STE C
SPOKANE VALLEY WA
99206-4094
US

IV. Provider business mailing address

826 N MULLAN RD STE C
SPOKANE VALLEY WA
99206-4094
US

V. Phone/Fax

Practice location:
  • Phone: 509-924-1580
  • Fax: 509-924-1619
Mailing address:
  • Phone: 509-924-1580
  • Fax: 509-924-1619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE60390327
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberB38275
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: