Provider Demographics
NPI:1386742526
Name:ELLIS, MICHAEL V (DDS)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:V
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:PO BOX 38
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:IN
Mailing Address - Zip Code:47541
Mailing Address - Country:US
Mailing Address - Phone:812-536-3011
Mailing Address - Fax:812-536-3000
Practice Address - Street 1:305 N MERIDIAN STREET
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:IN
Practice Address - Zip Code:47541
Practice Address - Country:US
Practice Address - Phone:812-536-3011
Practice Address - Fax:812-536-3000
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12006819122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist