MEDICARE: DAVID JOHN ELLINGSON 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	122300000X	Dentist	97397	AZ

General Provider Information

NPI Number	:	1689856148
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID JOHN ELLINGSON DDS

Provider Business Mailing Address
First Line	:	3549 E. BROWN RD.
Second Line	:	STE 104
City	:	MESA
State	:	AZ
Zip	:	85213
Country	:	US
Telephone Number	:	480-830-2956
Fax Number	:	490-830-3019

Provider Business Practice Location Address
First Line	:	3549 E BROWN RD
Second Line	:	STE 104
City	:	MESA
State	:	AZ
Zip	:	85213-5508
Country	:	US
Telephone Number	:	480-830-2956
Fax Number	:	480-830-3019

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

Provider Enumeration Date	:	11/27/2007
Last Update Date	:	05/13/2011

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Directions to “ DAVID JOHN ELLINGSON DDS” Practice Location

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