=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083098636
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LESLIE ELLINGSON D.D.S., M.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2015
-----------------------------------------------------
Last Update Date | 10/12/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1710 N 144TH ST
-----------------------------------------------------
City | OMAHA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68154-4715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-496-9733
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 320 INGLEWOOD CIR
-----------------------------------------------------
City | PAPILLION
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68133-3366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-719-4858
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 7251
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------