Provider Demographics
NPI:1841471737
Name:DAVID L. ELLIS, DDS, LTD
Entity type:Organization
Organization Name:DAVID L. ELLIS, DDS, LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:C
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-458-6733
Mailing Address - Street 1:3416 WOODLAWN ST
Mailing Address - Street 2:
Mailing Address - City:HOPEWELL
Mailing Address - State:VA
Mailing Address - Zip Code:23860-4738
Mailing Address - Country:US
Mailing Address - Phone:804-458-6733
Mailing Address - Fax:
Practice Address - Street 1:3416 WOODLAWN ST
Practice Address - Street 2:
Practice Address - City:HOPEWELL
Practice Address - State:VA
Practice Address - Zip Code:23860-4738
Practice Address - Country:US
Practice Address - Phone:804-458-6733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-19
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA11395261QD0000X
VA5245261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9179650Medicaid
VA9182633Medicaid