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General NPI Number Information
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NPI Number | 1083945711
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Entity Type | Organization
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Legal Business Name | PROGRESSIVE ORTHODONTICS, PLLC
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Dates
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Enumeration Date | 01/20/2010
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Last Update Date | 01/20/2010
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Provider Practice Location Address
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Address Line | 2110 E. FLAMINGO DR.
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City | BARTOW
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State | FL
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Zip | 33830-4236
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Country | US
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Telephone | 863-533-3302
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Fax | 863-534-3818
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Provider Business Mailing Address
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Address Line | 2110 E. FLAMINGO DR.
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City | BARTOW
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State | FL
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Zip | 33830-4236
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Country | US
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Telephone | 863-533-3302
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Fax | 863-534-3818
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Authorized Official
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Title or Position | PATNER/OWNER
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Name | DR. TIMOTHY M. ELLIS
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Credential | DMD, MS, PA
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Telephone | 863-533-3302
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | DN16931
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | DN10745
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License Number State | FL
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