MEDICARE: LARISA 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	1223G0001X	General Practice Dentistry	009502	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1881664514
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARISA ELLIS DDS

Provider Business Mailing Address
First Line	:	635 MAIN ST
Second Line	:	ATTN: CREDENTIALING DEPARTMENT
City	:	MIDDLETOWN
State	:	CT
Zip	:	06457-2718
Country	:	US
Telephone Number	:	860-347-6971
Fax Number	:	860-638-6601

Provider Business Practice Location Address
First Line	:	263 MAIN ST
Second Line	:
City	:	OLD SAYBROOK
State	:	CT
Zip	:	06475-2326
Country	:	US
Telephone Number	:	860-388-4433
Fax Number	:	860-388-4434

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

Provider Enumeration Date	:	01/25/2006
Last Update Date	:	07/08/2007

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