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General NPI Number Information
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NPI Number | 1013098698
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Entity Type | Individual
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Provider Name | CHARLES LEE ELLIS DDS, MD
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Gender | Male
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Dates
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Enumeration Date | 10/18/2006
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Last Update Date | 08/20/2025
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Provider Practice Location Address
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Address Line | 2353 S RIDGE ROAD
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City | GREEN BAY
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State | WI
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Zip | 54304-5069
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Country | US
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Telephone | 920-499-0471
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Fax | 920-499-8312
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Provider Business Mailing Address
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Address Line | 2353 S RIDGE ROAD
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City | GREEN BAY
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State | WI
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Zip | 54304-5069
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Country | US
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Telephone | 920-499-0471
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Fax | 920-499-8312
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 8919
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 0401411258
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License Number State | VA
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Taxonomy #3
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 019022235
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License Number State | IL
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Taxonomy #4
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Taxonomy Code | 204E00000X
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Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
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License Number | 0101058265
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License Number State | VA
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Taxonomy #5
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Taxonomy Code | 204E00000X
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Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
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License Number | 8919
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License Number State | NC
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Taxonomy #6
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 8919
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License Number State | NC
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