Provider Demographics
NPI:1992589444
Name:ELLSWORTH DENTAL LP
Entity type:Organization
Organization Name:ELLSWORTH DENTAL LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:L
Authorized Official - Last Name:ELLSWOTH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-476-5242
Mailing Address - Street 1:5701 W CHARLESTON BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-1256
Mailing Address - Country:US
Mailing Address - Phone:503-476-5242
Mailing Address - Fax:
Practice Address - Street 1:53 E LAKE MEAD PKWY
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89015-5832
Practice Address - Country:US
Practice Address - Phone:702-566-4133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-23
Last Update Date:2023-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty