Provider Demographics
NPI:1962085951
Name:ELLINGSEN MILLER, ELISE KATHRYN (DDS, MSD)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:KATHRYN
Last Name:ELLINGSEN MILLER
Suffix:
Gender:F
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:ELISE
Other - Middle Name:KATHRYN
Other - Last Name:ELLINGSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4213 STONE WAY N APT 410
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-7474
Mailing Address - Country:US
Mailing Address - Phone:509-389-7417
Mailing Address - Fax:
Practice Address - Street 1:1005 N EVERGREEN RD STE 201
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-1485
Practice Address - Country:US
Practice Address - Phone:509-921-5666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE611681591223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics