Healthcare Provider Details

I. General information

NPI: 1013098698
Provider Name (Legal Business Name): CHARLES LEE ELLIS DDS, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 08/20/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2353 S RIDGE ROAD
GREEN BAY WI
54304-5069
US

IV. Provider business mailing address

2353 S RIDGE ROAD
GREEN BAY WI
54304-5069
US

V. Phone/Fax

Practice location:
  • Phone: 920-499-0471
  • Fax: 920-499-8312
Mailing address:
  • Phone: 920-499-0471
  • Fax: 920-499-8312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number8919
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0401411258
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number019022235
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number0101058265
License Number StateVA
# 5
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number8919
License Number StateNC
# 6
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number8919
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: