Provider Demographics
NPI:1306061064
Name:ELLINGSON, DANIEL M (DMD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:M
Last Name:ELLINGSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6087 S REDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84123-6853
Mailing Address - Country:US
Mailing Address - Phone:801-969-7282
Mailing Address - Fax:
Practice Address - Street 1:6087 S REDWOOD RD
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84123-6853
Practice Address - Country:US
Practice Address - Phone:801-969-7282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT145305-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice