MEDICARE: JEFF D. ELLARD D.D.S.

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	1223P0221X	Pediatric Dentistry	3507	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	810768	OTHER		UNITED CONCORDIA PROV. #

General Provider Information

NPI Number	:	1376547364
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFF D. ELLARD D.D.S.

Provider Business Mailing Address
First Line	:	541 SHADOWS LN
Second Line	:	STE B
City	:	BATON ROUGE
State	:	LA
Zip	:	70806-6531
Country	:	US
Telephone Number	:	225-924-2010
Fax Number	:	225-926-5872

Provider Business Practice Location Address
First Line	:	541 SHADOWS LN
Second Line	:	STE B
City	:	BATON ROUGE
State	:	LA
Zip	:	70806-6531
Country	:	US
Telephone Number	:	225-924-2010
Fax Number	:	225-926-5872

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

Provider Enumeration Date	:	06/08/2005
Last Update Date	:	07/08/2007

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