MEDICARE: RANDAL W ELLIS DMD PLLC

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	DE00008470	WA

General Provider Information

NPI Number	:	1326051285
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RANDAL W ELLIS DMD PLLC

Provider Business Mailing Address
First Line	:	PO BOX 608
Second Line	:
City	:	DEMING
State	:	WA
Zip	:	98244
Country	:	US
Telephone Number	:	360-592-1100
Fax Number	:	360-592-5067

Provider Business Practice Location Address
First Line	:	3739 MT BAKER HWY
Second Line	:
City	:	EVERSON
State	:	WA
Zip	:	98247-9406
Country	:	US
Telephone Number	:	360-592-1100
Fax Number	:	360-592-5067

Authorized Official
Title or Position	:	DENTIST/OWNER
Name	:	RANDAL W ELLIS
Credential	:	DMD
Telephone Number	:	360-592-1100

Provider Enumeration Date	:	08/14/2006
Last Update Date	:	05/03/2012

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