Provider Demographics
NPI:1306955075
Name:NEIBURGER, ELLIS J (DDS)
Entity type:Individual
Prefix:DR
First Name:ELLIS
Middle Name:J
Last Name:NEIBURGER
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 1:1000 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-2938
Mailing Address - Country:US
Mailing Address - Phone:847-244-0292
Mailing Address - Fax:
Practice Address - Street 1:1000 NORTH AVE
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-2938
Practice Address - Country:US
Practice Address - Phone:847-244-0292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19013414122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist