MEDICARE: CRYSTAL ELLIS DDS, LLC.

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	14220	MD

General Provider Information

NPI Number	:	1700144136
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRYSTAL ELLIS DDS, LLC.

Provider Business Mailing Address
First Line	:	8455 COLESVILLE RD
Second Line	:	SUITE 102
City	:	SILVER SPRING
State	:	MD
Zip	:	20910-3315
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8455 COLESVILLE RD
Second Line	:	SUITE 102
City	:	SILVER SPRING
State	:	MD
Zip	:	20910-3315
Country	:	US
Telephone Number	:	240-565-8159
Fax Number	:

Authorized Official
Title or Position	:	MANAGING OWNER
Name	:	DR. CRYSTAL GORDON ELLIS
Credential	:	DDS
Telephone Number	:	240-565-8159

Provider Enumeration Date	:	04/23/2012
Last Update Date	:	04/23/2012

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