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General NPI Number Information
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NPI Number | 1093971749
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Entity Type | Individual
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Provider Name | ERIC EDWARD ELLIS DMD
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Gender | Male
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Dates
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Enumeration Date | 08/01/2008
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Last Update Date | 11/09/2010
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Provider Practice Location Address
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Address Line | 31307 N 137TH AVE
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City | PEORIA
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State | AZ
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Zip | 85383-7941
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Country | US
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Telephone | 586-322-9041
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Fax |
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Provider Business Mailing Address
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Address Line | 31307 N 137TH AVE
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City | PEORIA
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State | AZ
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Zip | 85383-7941
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Country | US
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Telephone | 586-322-9041
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Fax |
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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 | 2901019386
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 2901019386
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License Number State | MI
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Taxonomy #3
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 7708
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License Number State | AZ
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