MEDICARE: DR. GARY LYNN ELLIS 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	1223P0106X	Oral and Maxillofacial Pathology Dentistry	5129775-9921	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5129775-9921	OTHER	UT	DENTAL LICENSE

General Provider Information

NPI Number	:	1700840717
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY LYNN ELLIS DDS

Provider Business Mailing Address
First Line	:	500 CHIPETA WAY
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-1221
Country	:	US
Telephone Number	:	801-583-2787
Fax Number	:	801-584-5255

Provider Business Practice Location Address
First Line	:	500 CHIPETA WAY
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-1221
Country	:	US
Telephone Number	:	801-583-2787
Fax Number	:	801-584-5255

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

Provider Enumeration Date	:	04/14/2006
Last Update Date	:	07/08/2007

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