MEDICARE: DR. BENJAMIN ELLSWORTH 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	6506	NV

General Provider Information

NPI Number	:	1760774558
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BENJAMIN ELLSWORTH D.D.S.

Provider Business Mailing Address
First Line	:	505 BACHELOR BUTTON ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89138-6077
Country	:	US
Telephone Number	:	424-744-7695
Fax Number	:

Provider Business Practice Location Address
First Line	:	505 BACHELOR BUTTON ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89138-6077
Country	:	US
Telephone Number	:	424-744-7695
Fax Number	:

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

Provider Enumeration Date	:	05/11/2011
Last Update Date	:	08/05/2016

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