MEDICARE: DR. HARLEY A. ELLINGER JR. 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	1223P0300X	Periodontics	3670	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3670	OTHER	NC	DENTAL LICENSE

General Provider Information

NPI Number	:	1386649630
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HARLEY A. ELLINGER JR. D.D.S.

Provider Business Mailing Address
First Line	:	3325 SPRINGBANK LN
Second Line	:	STE 140
City	:	CHARLOTTE
State	:	NC
Zip	:	28226-3364
Country	:	US
Telephone Number	:	704-544-2224
Fax Number	:	704-544-2259

Provider Business Practice Location Address
First Line	:	3325 SPRINGBANK LN
Second Line	:	STE 140
City	:	CHARLOTTE
State	:	NC
Zip	:	28226-3364
Country	:	US
Telephone Number	:	704-544-2224
Fax Number	:	704-544-2259

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

Provider Enumeration Date	:	06/14/2005
Last Update Date	:	07/08/2007

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Directions to “ DR. HARLEY A. ELLINGER JR. D.D.S.” Practice Location

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