Provider Demographics
NPI:1588767040
Name:ELLIS, TIMOTHY MARK (DMD MS PA)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:MARK
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DMD MS PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 E FLAMINGO DR
Mailing Address - Street 2:
Mailing Address - City:BARTOW
Mailing Address - State:FL
Mailing Address - Zip Code:33830-4236
Mailing Address - Country:US
Mailing Address - Phone:863-533-3302
Mailing Address - Fax:863-534-3818
Practice Address - Street 1:2110 E FLAMINGO DR
Practice Address - Street 2:
Practice Address - City:BARTOW
Practice Address - State:FL
Practice Address - Zip Code:33830-4236
Practice Address - Country:US
Practice Address - Phone:863-533-3302
Practice Address - Fax:863-534-3818
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN107451223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics