Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 2901019386 | MI |
N | 1223P0221X | Pediatric Dentist | 2901019386 | MI |
Y | 1223P0221X | Pediatric Dentist | 7708 | AZ |
NPI | 1093971749 |
---|---|
Provider Name | Eric Edward Ellis |
First Address | Peoria, AZ 85383-7941 |
Second Address | Peoria, AZ 85383-7941 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/08/2008 |
Last Update Date | 09/11/2010 |