Provider Demographics
NPI:1699730895
Name:ELLISON, CORBET KEVIN (DDS)
Entity type:Individual
Prefix:DR
First Name:CORBET
Middle Name:KEVIN
Last Name:ELLISON
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 1:1304 DART ST APT A
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77007-6243
Mailing Address - Country:US
Mailing Address - Phone:281-725-0103
Mailing Address - Fax:
Practice Address - Street 1:11233 SHADOW CREEK PKWY STE 120
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-7345
Practice Address - Country:US
Practice Address - Phone:281-741-5247
Practice Address - Fax:281-741-5354
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN10002881223P0221X
TX235891223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX188083306Medicaid