Provider Demographics
NPI:1184719262
Name:ELLIS, MARK ALLEN (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLEN
Last Name:ELLIS
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 1:910 AVERITT RD
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-9540
Mailing Address - Country:US
Mailing Address - Phone:317-859-9450
Mailing Address - Fax:317-859-9475
Practice Address - Street 1:910 AVERITT RD
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-9540
Practice Address - Country:US
Practice Address - Phone:317-859-9450
Practice Address - Fax:317-859-9475
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010547A1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200500300Medicaid