Provider Demographics
NPI:1063254381
Name:SEVERANCE, ELLIE (DDS)
Entity type:Individual
Prefix:DR
First Name:ELLIE
Middle Name:
Last Name:SEVERANCE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728 HOBBS RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-6817
Mailing Address - Country:US
Mailing Address - Phone:573-691-7700
Mailing Address - Fax:
Practice Address - Street 1:404 N 4TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:MO
Practice Address - Zip Code:64076-1152
Practice Address - Country:US
Practice Address - Phone:573-691-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-07
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20240192831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice