Provider Demographics
NPI:1306911581
Name:ELLIS, DONALD MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:MICHAEL
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 JOHN MARR DR STE 401
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-3310
Mailing Address - Country:US
Mailing Address - Phone:703-750-9393
Mailing Address - Fax:703-750-5420
Practice Address - Street 1:4600 JOHN MARR DR STE 401
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-3310
Practice Address - Country:US
Practice Address - Phone:703-750-9393
Practice Address - Fax:703-750-5420
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014111311223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics