Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 7010 | NV |
NPI | 1003314535 |
---|---|
Provider Name | Dr. Evan Bale Ellsworth |
First Address | Las Vegas, NV 89118-3256 |
Second Address | Henderson, NV 89074-3385 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/01/2018 |
Last Update Date | 17/03/2019 |