Healthcare Provider Details

I. General information

NPI: 1720016900
Provider Name (Legal Business Name): ROYAL ELLINGER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MILWAUKEE VA MEDICAL CENTER / DENTAL CLINIC 5000 NATIONAL AVE
MILWAUKEE WI
53295-0001
US

IV. Provider business mailing address

7995 W LAKE POINTE DR
FRANKLIN WI
53132-8529
US

V. Phone/Fax

Practice location:
  • Phone: 414-384-2000
  • Fax: 414-389-4162
Mailing address:
  • Phone: 414-384-2000
  • Fax: 414-389-4162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number5001965
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: