MEDICARE: DR. RICHARD D. ELLSWORTH DDS

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	7107	IN

General Provider Information

NPI Number	:	1083714885
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD D. ELLSWORTH DDS

Provider Business Mailing Address
First Line	:	150 PROFESSIONAL CT.
Second Line	:	STE A
City	:	LAFAYETTE
State	:	IN
Zip	:	47905-5153
Country	:	US
Telephone Number	:	765-449-2757
Fax Number	:	765-449-2759

Provider Business Practice Location Address
First Line	:	150 PROFESSIONAL CT.
Second Line	:	STE A
City	:	LAFAYETTE
State	:	IN
Zip	:	47905-5153
Country	:	US
Telephone Number	:	765-449-2757
Fax Number	:	765-449-2759

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/22/2006
Last Update Date	:	07/08/2007

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