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General NPI Number Information
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NPI Number | 1740304542
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Entity Type | Individual
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Provider Name | JACQUELINE DENISE ELLIS DMD
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Gender | Female
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Dates
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Enumeration Date | 03/19/2007
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Last Update Date | 07/09/2007
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Provider Practice Location Address
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Address Line | 5535 NW 7TH AVE
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City | MIAMI
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State | FL
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Zip | 33127-1401
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Country | US
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Telephone | 305-759-1145
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Fax | 305-759-1145
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Provider Business Mailing Address
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Address Line | 1607 PRESIDENTIAL WAY
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City | MIAMI
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State | FL
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Zip | 33179-6437
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Country | US
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Telephone | 305-757-7763
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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 | DN0011584
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License Number State | FL
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