MEDICARE: JOSHUA L ELLISS DMD LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DD3482	NM

General Provider Information

NPI Number	:	1023377363
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOSHUA L ELLISS DMD LLC

Provider Business Mailing Address
First Line	:	3015 HILLRISE DR
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-4703
Country	:	US
Telephone Number	:	575-522-0454
Fax Number	:	575-522-3472

Provider Business Practice Location Address
First Line	:	3015 HILLRISE DR
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-4703
Country	:	US
Telephone Number	:	575-522-0454
Fax Number	:	575-522-3472

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JOSHUA LEVI ELLISS
Credential	:	DMD
Telephone Number	:	575-522-0454

Provider Enumeration Date	:	05/07/2012
Last Update Date	:	05/07/2012

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