Healthcare Provider Details

I. General information

NPI: 1174458509
Provider Name (Legal Business Name): ELLICKSON DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5510 MEDICAL CIR
MADISON WI
53719-1239
US

IV. Provider business mailing address

5510 MEDICAL CIR
MADISON WI
53719-1239
US

V. Phone/Fax

Practice location:
  • Phone: 608-274-5510
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LUKE ELLICKSON
Title or Position: OWNER
Credential: DDS
Phone: 417-569-6575