Provider Demographics
NPI:1407022783
Name:ELLIS, CRYSTAL G (DDS)
Entity type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:G
Last Name:ELLIS
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 1:8455 COLESVILLE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-6363
Mailing Address - Country:US
Mailing Address - Phone:301-588-1099
Mailing Address - Fax:301-588-1699
Practice Address - Street 1:8455 COLESVILLE RD STE 102
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-6363
Practice Address - Country:US
Practice Address - Phone:301-588-0030
Practice Address - Fax:301-588-1699
Is Sole Proprietor?:No
Enumeration Date:2008-05-06
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD142201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice