Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | 5005 | ME |
NPI | 1255565065 |
---|---|
Provider Name | Steven L. Ellis |
First Address | Old Orchard Beach, ME 04064-1600 |
Second Address | Old Orchard Beach, ME 04064-1600 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/05/2009 |
Last Update Date | 07/05/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
431742900 | MAINE CARE (01) | ME |