Provider Demographics
NPI:1285108563
Name:ELLIS ENDODONTICS, PA
Entity type:Organization
Organization Name:ELLIS ENDODONTICS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:BRANT
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSCD
Authorized Official - Phone:832-452-3169
Mailing Address - Street 1:303 LONGMIRE RD UNIT 901
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-2101
Mailing Address - Country:US
Mailing Address - Phone:936-760-2222
Mailing Address - Fax:936-760-2233
Practice Address - Street 1:303 LONGMIRE RD UNIT 901
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-2101
Practice Address - Country:US
Practice Address - Phone:936-760-2222
Practice Address - Fax:936-760-2233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-19
Last Update Date:2019-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty