Provider Demographics
NPI:1386139541
Name:ELLING, AMANDA (DDS)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:
Last Name:ELLING
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 1:313 W PARKER ST STE A
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:TX
Mailing Address - Zip Code:75839-7612
Mailing Address - Country:US
Mailing Address - Phone:817-709-3006
Mailing Address - Fax:
Practice Address - Street 1:313 W PARKER ST STE A
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:TX
Practice Address - Zip Code:75839-7612
Practice Address - Country:US
Practice Address - Phone:817-709-3006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX342331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice